Key result
IV calcium and insulin-dextrose rapidly restores ICD pacing capture in severe hyperkalemia from BRASH syndrome.
Why the study?
This case report describes a presentation of BRASH syndrome complicated by failure of implantable cardioverter-defibrillator pacing capture in the setting of severe hyperkalemia.
Case Report (n=1)
No
In patients presenting with BRASH syndrome and failure of ICD pacing capture refractory to atropine, prompt medical correction of severe hyperkalemia and emergent dialysis can rapidly restore myocardial excitability and device capture, avoiding unnecessary transvenous pacemaker placement.
Hyperkalemia correction may restore ICD capture in BRASH syndrome; this case leaves open need for prospective validation before practice change.
This case report describes a 54-year-old woman with end-stage renal disease and heart failure who presented with BRASH syndrome: a synergistic cycle of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia. The patient, who was adherent to metoprolol and amiodarone, presented with a profound ventricular escape rhythm of 16 bpm and hemodynamic instability after missing 4 days of hemodialysis. An interesting complication was the failure of her implantable cardioverter-defibrillator (ICD) to achieve pacing capture, a phenomenon likely driven by a potassium level of 7.8 mEq/L causing myocardial inexcitability. Additionally, the recent uptitration of a carotid sinus nerve stimulator for baroreflex activation therapy may have contributed to the bradycardic cycle. Immediate medical management of hyperkalemia with calcium, insulin, and dextrose successfully restored ICD capture, followed by emergent dialysis, which normalized her rhythm. This case emphasizes that BRASH syndrome should be considered in undifferentiated bradycardia, particularly when refractory to atropine, and highlights that correcting the underlying metabolic derangement is essential to restoring cardiac excitability and device function.
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STEPHEN et al. (2026) conducted a case report in BRASH syndrome with severe hyperkalemia and failure of ICD pacing capture (n=1). Medical hyperkalemia management (IV calcium gluconate, insulin, dextrose), CSNS deactivation, and emergent hemodialysis was evaluated on Restoration of ICD pacing capture and normalization of cardiac rhythm. Immediate administration of IV calcium, insulin, and dextrose restored ICD pacing capture from 16 to 50 bpm in a patient with BRASH syndrome and a potassium of 7.8 mEq/L.
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