Abstract
BACKGROUND: Bradycardia, Renal failure, Atrioventricular node blockade, Shock, and Hyperkalemia (BRASH) syndrome is an underrecognized but potentially fatal cardiometabolic emergency. Risk factors for developing BRASH syndrome overlap with comorbidities of patients undergoing coronary angiography. CASE SUMMARY: A 75-year-old woman with chronic kidney disease stage 4 developed contrast-induced nephropathy, profound bradycardia, and shock after percutaneous coronary intervention. Despite vasopressor support, her shock progressed to brainstem areflexia. Renal replacement therapy reversed her metabolic derangements and hemodynamic instability, leading to full neurologic recovery. DISCUSSION: This case highlights the rapid, life-threatening progression of BRASH syndrome, particularly in patients with chronic kidney disease receiving atrioventricular node blockers and contrast exposure. Early recognition, temporizing measures, and renal replacement were pivotal. TAKE-HOME MESSAGES: Patients undergoing coronary angiography may be at high risk for BRASH syndrome. Awareness, timely identification, and supportive interventions, including renal replacement therapy, can be lifesaving.