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July 18, 2026Case Reports in Critical CareOpen Access

BRASH Syndrome Unmasked: Digoxin Toxicity in the Setting of Cardiogenic Shock and Multiorgan Dysfunction

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Why the study?

Digoxin has a narrow therapeutic index susceptible to disruption in critically ill patients, making its use in acute decompensated heart failure and cardiogenic shock controversial.

Population

A 75-year-old woman with chronic HFrEF and 2:1 atrial flutter

Design

Case report

Key result

A 75-year-old woman developed BRASH syndrome and cardiogenic shock following digoxin and amiodarone treatment, which resolved with supportive therapy and withdrawal of AV-nodal-blocking agents.

Authors

SBSpencer BoehmJBJordan Bruni

Discussion

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Overview

May signal BRASH syndrome risk with combined AV-nodal blockers; leaves open incidence and management guidance.

Key Points

  • This report aims to illustrate the presentation and management of digoxin toxicity in the context of BRASH syndrome in critically ill patients.
  • Case presentation of a 75-year-old woman with chronic heart failure and acute decompensated heart failure.
  • Assessment of digoxin levels, metabolic derangements, and clinical symptoms during hospital course.
  • Supportive therapy and correction of physiologic abnormalities were prioritized over drug level management.
  • Patient developed progressive bradycardia and cardiogenic shock after digoxin and amiodarone treatment.
  • Serum digoxin levels were supratherapeutic, but bradyarrhythmias persisted despite normalization of levels.
  • Patient improved with supportive measures, indicating the importance of recognizing BRASH syndrome.

Study Design

Type

Case Report (n=1)

Structured PICO

P
Population
A 75-year-old woman with chronic heart failure with reduced ejection fraction who developed BRASH syndrome and cardiogenic shock after treatment with digoxin and amiodarone.
E
Exposure
Digoxin and amiodarone
O
Outcome
Development and clinical course of BRASH syndrome (bradycardia, renal failure, AV-nodal blockade, shock, and hyperkalemia)safety

This case highlights the risk of BRASH syndrome from digoxin and amiodarone interaction in HFrEF patients and emphasizes supportive care over reliance on serum drug levels.

Cite This Study

Boehm et al. (2026) conducted a case report in BRASH syndrome and cardiogenic shock (n=1). Digoxin and amiodarone was evaluated. A 75-year-old woman developed BRASH syndrome and cardiogenic shock following digoxin and amiodarone treatment, which resolved with supportive therapy and withdrawal of AV-nodal-blocking agents.

synapsesocial.com/papers/6a5b38f68167787360d24ddbhttps://doi.org/10.1155/crcc/8778210
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