(1433) Pacing Through BRASH: Role of Epinephrine in Diagnosis

Introduction: Bradycardia-Renal Failure-Atrioventricular Nodal Blockade-Shock-Hyperkalemia (BRASH) 
is an underdiagnosed syndrome which can occur in elderly patients with underlying cardiovascular disease, often triggered by volume depletion. We present an unusual case of BRASH syndrome in a cancer patient where epinephrine infusion was used both as a diagnostic and therapeutic tool.

Description: A 95-year-old female with history of hypertension on atenolol and high-grade ovarian cancer treated with chemotherapy presented after a syncopal episode. She was hypotensive and bradycardic with heart rate of 36 beats per minute and noted to have junctional rhythm on ECG, acute kidney injury with low urine output, and hyperkalemia. Transvenous pacemaker placement failed due to technical difficulties. The patient was started on an epinephrine infusion and the hyperkalemia was treated with insulin/dextrose, calcium gluconate and intravenous fluids. The bradycardia and hypotension resolved with epinephrine and her renal function improved with increased urine output and resolution of hyperkalemia. With improved hemodynamics, the epinephrine infusion was discontinued. However, the patient again became bradycardic and hypotensive, with oliguria and hyperkalemia. Epinephrine infusion was restarted, again with resolution of bradycardia, hypotension, oliguria, and hyperkalemia. The patient was transferred for permanent pacemaker placement with resolution of her symptoms and was subsequently discharged home.

Discussion: In our patient, the synergistic effect of atrioventricular (AV) nodal blockade from the beta-blocker and the hyperkalemia was likely the culprit mechanism for the profound bradycardia.  Despite discontinuation of the atenolol and correction of hyperkalemia, the bradycardia did not improve until epinephrine infusion was initiated. Once epinephrine was started, our patient's condition almost immediately improved. When epinephrine was weaned off, the patient became bradycardic again and renal function worsened. Thus, epinephrine served as both a diagnostic and treatment tool for managing this patient. Patients with BRASH may still require pacemaker implantation for symptomatic bradycardia despite conservative treatment, which our patient ultimately required.