Nikhil Prasad Fact checked by:Thailand Medical News Team Aug 16, 2026 46 minutes ago
A striking medical case involving a 55-year-old woman with COVID-19 myocarditis, severe heart dysfunction and worsening kidney injury suggests that COVID-19 may directly or indirectly create conditions capable of triggering a dangerous complication known as BRASH syndrome.
COVID-19-associated myocarditis and worsening kidney dysfunction may create conditions that help trigger
the potentially life-threatening BRASH syndrome
BRASH stands for bradycardia, renal failure, atrioventricular nodal blockade, shock and hyperkalemia. The syndrome develops when kidney dysfunction, abnormal potassium levels and medications that slow electrical conduction through the heart interact, potentially creating a rapidly worsening cycle.
Researchers And Their Institutions
The case report was authored by Dr Adrija Mehta from the Department of Internal Medicine at BronxCare Health System, Bronx, New York, United States, along with Dr Sai Allu and Dr Nassim Krim from Cardiology at Mount Sinai Morningside-BronxCare Health System, New York, United States.
COVID-19 Myocarditis Sets the Stage
The woman had asthma, hypertension, type 2 diabetes and stage 3 chronic kidney disease. She sought medical attention after two weeks of breathlessness, productive cough, palpitations and swelling of her legs. Testing confirmed SARS-CoV-2 infection.
Doctors discovered atrial flutter with a rapid heart rate. Further investigations showed pulmonary edema, an enlarged heart and severely impaired pumping ability. Her heart's ejection fraction was only 22%, and a large blood clot was found inside the left ventricle.
Kidney function was also deteriorating. Creatinine was 2.8 mg/dL on admission, compared with a baseline of approximately 2.0 mg/dL.
Doctors used diltiazem and metoprolol to control the rapid heartbeat. Metoprolol was progressively increased because the fast heart rhythm persisted, while amiodarone was subsequently added.
Patient Suddenly Develops BRASH Syndrome
By hospital day five, the situation changed dramatically. The woman's heart rate plunged to below 30 beats per minute. She developed dangerously low blood pressure, altered mental status and severe hypoglycemia that responded poorly to conventional treatment.
Kidney function had worsened substantially, with creatinine rising to 4.5 mg/dL. Potassium increased from 4.5 to 6.5 mmol/L, while arterial pH fell to 7.12, indicating severe acidosis. Lactate surged from 2.3 to 12.1 mmol/L.
Atropine failed to correct her extremely slow heartbeat, while dextrose and glucagon struggled to reverse the low blood sugar.
As this Thailand
Medical News report highlights, these unusual treatment failures became important clues pointing doctors toward BRASH syndrome.
How COVID-19 Could Indirectly Trigger the Dangerous Spiral
The researchers describe several processes contributing to the woma
n's severe heart damage, including COVID-19 myocarditis, sustained atrial flutter and cocaine-associated myocardial injury. COVID-19-related inflammation and endothelial dysfunction were also considered part of a highly pro-thrombotic environment.
The BRASH episode itself appears to have resulted from a dangerous interaction between worsening kidney failure, rising potassium and AV-node-blocking medication.
Metoprolol slowed electrical conduction through the heart, while hyperkalemia further suppressed cardiac conduction. Together, these effects produced severe bradycardia that neither factor would necessarily have caused independently.
The slower heartbeat then reduced cardiac output, worsening shock and kidney function and potentially intensifying the metabolic abnormalities—a vicious physiological cycle.
Cardiac Arrest, Blood Clots and Stroke
Doctors immediately stopped heart-rate-slowing medications, administered norepinephrine and dopamine and began urgent hemodialysis. During dialysis, the patient suffered cardiac arrest but regained spontaneous circulation within three minutes.
Her ejection fraction subsequently fell to 15%. Multiple blood clots developed inside both sides of the heart, and she later suffered an ischemic stroke consistent with a clot traveling from the heart.
She eventually stabilized and was discharged with outpatient hemodialysis, warfarin and carefully managed heart-rate medications.
Conclusions
This case does not prove that COVID-19 directly causes BRASH syndrome. However, it demonstrates how COVID-19 myocarditis and associated critical illness may contribute to heart and kidney deterioration that creates favorable conditions for BRASH to emerge. Recognizing the combination of severe bradycardia, kidney failure, hyperkalemia, shock and unusual treatment resistance could therefore be lifesaving.
The study findings were published in the peer reviewed journal: HeartRhythm Case Reports.
https://www.sciencedirect.com/science/article/pii/S2214027126002964
Read Also:
https://www.thailandmedical.news/articles/coronavirus
https://www.thailandmedical.news/articles/long-covid
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