Atrial fibrillation in sepsis and the potential effects of propafenone and levocarnitine

Actually sepsis is one of the most important health problems, as the incidence of it in the world is high and continues to grow, and mortality reaches 40–60%, especially with the development of septic shock. Frequent heart damage in sepsis – septic cardiomyopathy (an established term for sepsis-caused by acute cardiac dysfunction syndrome unrelated to ischemia due to damage to the coronary arteries) – is often complicated by the occurrence of cardiac arrhythmias. Ventricular arrhythmias are rare, and atrial fibrillation develops in 20–30% of cases, reaching 45% with septic shock. At the same time, mortality increases by about 2–3 times if attempts at cardioversion are unsuccessful. However, the issues of antiarrhythmic therapy have not yet been regulated. The Russian and Eurasian clinical guidelines for the treatment of atrial fibrillation (2025) do not mention sepsis. And the recommendations of the European Society of Cardiology and the Association of Cardiothoracic Surgeons (2024), supplemented by the European Heart Rhythm Association (2025), only state that sepsis is a trigger for atrial fibrillation and a risk factor for its subsequent recurrence in almost half of the discharged patients with sepsis, and the degree of inflammation correlates with the frequency of its development and recurrence. Drugs commonly used for cardioversion – beta-blockers, calcium antagonists, amiodarone – can worsen the situation, negatively affecting the hemodynamics of septic patients, especially in shock. The culprits of the hipotensive effect of amiodarone, in particular, are due of the emulsifier polysorbate-80 and benzyl alcohol in its composition. Based on an analysis of current clinical studies and our own clinical experience, the article examines the use of propafenone in this case, devoid of cardiodepressive properties. It is also advisable to use levocarnitine adjuvantly, which has positive inotropic and antioxidant properties, as well as being able to resist inflammatory and proarrhythmic links in the pathogenesis of sepsis, and prevent recurrence.

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