New York cardiologist with 30 years of experience warns of 'life-threatening risk' from combining these 2 heart drugs
Dr Evan Levine warns that mixing these two drugs can lead to BRASH syndrome — a dangerous mix of slow heart rate, kidney failure, shock and high potassium.
A cardiologist with over 30 years of experience is sounding the alarm about a “potentially life-threatening risk” when two common heart medications are prescribed together, a combination that can trigger a dangerous condition known as BRASH syndrome. Also read | Tennessee cardiologist shares '1 vital sign doctors never measure but your phone does every day'
In a December 11 Instagram video, Dr Evan Levine, a cardiologist at Mount Sinai Hospital in New York City, strongly advised medical professionals to exercise extreme caution or seek alternative treatments when combining certain beta blockers and specific non-dihydropyridine calcium channel blockers for at-risk patients, particularly the elderly. He wrote in his caption, “Doctors should have great caution or choose an alternative when combining these two drugs, especially in older patients.”
The BRASH syndrome danger
Dr Levine explained that the danger arises from a vicious cycle named BRASH syndrome, an acronym standing for Bradycardia (dangerously slow heart rate), Renal failure, AV Nodal blockade, Shock, and Hyperkalemia. Both beta blockers (such as metoprolol, tenalol, and carvedilol) and certain calcium channel blockers (like diltiazem or verapamil) work by slowing the heart's electrical signals at the AV node. While excellent individually for managing blood pressure or slowing the heart rate, the combination becomes a "perfect storm" in certain scenarios, he said.
Dr Levine stated in the video: “I want to talk to you about a crucial, potentially life-threatening risk for older adults who take common heart medications, specifically those that slow your heart rate... These drugs are excellent, but they share a common problem. They slow the electrical signals at a tiny part of your heart called the AV node that keeps your heart beating.”
The vicious cycle in the elderly
According to Dr Levine, the risk is significantly higher for elderly individuals, who may become dehydrated due to an illness like a bad cold or the flu, leading to acute kidney failure. Dr Levine said, “What happens is it's a vicious cycle, specifically in the elderly, on the loop and the calcium blocker. They get dehydrated. Maybe they had a bad cold or the flu. They're not drinking enough water, and their kidneys suffer the consequences. Those sick kidneys have a problem clearing the heart medicines, the beta blocker and the calcium blocker, and the drug levels skyrocket.”
The failing kidneys also have trouble eliminating potassium, resulting in increased potassium levels. Dr Levine warned that the combination of high drug levels and high potassium works synergistically to severely slow the heart rate far beyond what is expected. This results in the blood pressure tanking (shock), which, in turn, worsens kidney function.
He said, “They (elderly) also have a problem getting rid of potassium, so your potassium levels increase. And these two things are a perfect storm. That high drug level and high potassium work together to severely slow your heart rate much more than expected, and the blood pressure tanks, which then makes your kidneys fail even worse. It's a terrible downward spiral.”
Advice to doctors and patients
Dr Levine highlighted the need for vigilance from physicians, noting that alternative drug therapies exist (like amlodipine, a different type of calcium channel blocker, or amiodarone, which does not slow the AV node) that may not carry the same risk. He concluded his warning with critical advice for patients: “If you feel significantly unwell, remember, call your doctor or seek urgent medical care immediately. Tell the medical team about the heart medications you're taking.”
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This article is for informational purposes only and not a substitute for professional medical advice.
