The BRASH syndrome, a synergistic arrhythmia phenomenon.

BRASH syndrome is a relatively novel clinical entity with profound bradycardia secondary to simultaneous metabolic derangement and drug toxicity. The syndrome is a clinical pentad of bradycardia, acute kidney injury, use of atrioventricular nodal blocking agents, shock, and hyperkalemia. It is widely underrecognized with selectively few reports, mainly in the elderly population. We present a 43-year-old woman on two oral atrioventricular blocking agents who presented with 1 week of increasing lethargy with rapid deterioration into cardiac arrest with subsequent shock postresuscitation. She was found to have hyperkalemia, metabolic acidosis, and acute kidney injury on arrival. Her initial electrocardiogram was remarkable for sinus arrest and junctional bradycardia. She was treated with a temporary pacemaker, renal replacement therapy, and potassium-lowering agents, with subsequent improvement resulting in conversion to normal sinus rhythm.

Decrease in acute coronary syndrome mortality in Pleven district: implementation of scientific evidence into everyday practice.

Cardiovascular mortality in Bulgaria has increased for the last 25 years, contrary to the rest of the EU countries. One of the reasons is high in-hospital mortality due to acute myocardial infarction. The Bulgarian Cardiac Institute has established a modern cardiac hospital with a catheterization laboratory (cathlab) in the Medical University in Pleven, which helps it decrease acute coronary syndrome (ACS) mortality, taking all the necessary steps according to the guidelines of the European Society of Cardiology (ESC).

The misuse of clinical paths as an instrument for funding inpatient care in Bulgaria.

Clinical paths in Bulgaria are used not as a method for quality assessment, but as an instrument to fund hospitals. Their use and incompleteness cause limited access of all Bulgarian citizens to the international treatment guidelines. That way quality of treatment worsens and mortality increases. The Bulgarian system of regulated medical guidelines by all therapeutic and surgical lines still suffers many deficiencies. The National Health Insurance Fund should use the system of clinical paths for quality control as well.