New-onset atrial fibrillation in sepsis is associated with a 2- to 3-fold increase in mortality, while propafenone and beta-blockers are preferable to amiodarone for rhythm and rate control.
Systematic Review
What is the comparative efficacy and safety of amiodarone, alternative rhythm/rate control strategies, and metabolic therapy in adults with sepsis-associated atrial fibrillation?
Propafenone and short-acting β1-blockers may be preferable to amiodarone for managing sepsis-associated atrial fibrillation in patients without substantial myocardial remodeling.
Objective. To analyze the role of amiodarone, alternative rhythm and rate control strategies, and metabolic therapy in sepsis-associated atrial fibrillation (AF). Methods. A systematic search was conducted in PubMed/MEDLINE, Embase, Cochrane Library, and RSCI up to January 2026. Randomized controlled trials (RCTs), prospective and retrospective cohort studies (n≥30), and controlled experimental studies in adults with sepsis/septic shock and supraventricular tachyarrhythmias were included. Additionally, RCTs of succinate-containing and metabolic therapies in other critical conditions (acute myocardial infarction, cardiac surgery, stroke, severe traumatic brain injury) evaluating arrhythmic or mechanistically relevant endpoints were considered. Results. New-onset AF in sepsis is associated with a 2- to 3-fold increase in mortality. Amiodarone effectively controls rhythm and rate but does not improve survival in septic shock and carries risks of negative inotropy, hypotension, torsade de pointes, and organ toxicity. In an RCT, propafenone provided faster cardioversion and fewer AF recurrences compared to amiodarone with similar mortality; a survival benefit was observed in patients without significant left atrial dilatation. Short-acting β1-blockers (esmolol, landiolol) safely control heart rate in hyperdynamic shock. Simultaneous correction of hypokalemia and hypomagnesemia increases the likelihood of spontaneous cardioversion. Succinate-containing infusions (Reamberin) and Cytoflavin in RCTs for critical illness reduce reperfusion arrhythmias and improve left ventricular systolic function. Discussion. Evidence supporting propafenone and β-blockers is derived from a limited number of RCTs with heterogeneous inclusion criteria. Data on metabolic therapy in sepsis-associated AF are extrapolated from studies in other critical conditions (AMI, COVID-19). Direct multicenter RCTs of succinate-based therapies with arrhythmic endpoints in sepsis are lacking. Conclusion. In sepsis-associated AF, amiodarone should be reserved for patients with significant structural heart disease and left atrial dilatation. Propafenone and short-acting β1-blockers are preferable alternatives in patients without substantial myocardial remodeling. Succinate-containing and metabolic therapy is pathogenetically justified as an organ-protective adjuvant but requires dedicated RCTs in the sepsis population. Funding source. The authors declare no external funding.
Симутис et al. (Thu,) conducted a systematic review in Sepsis-associated atrial fibrillation. Amiodarone, alternative strategies (propafenone, beta-blockers), and metabolic therapy was evaluated. New-onset atrial fibrillation in sepsis is associated with a 2- to 3-fold increase in mortality, while propafenone and beta-blockers are preferable to amiodarone for rhythm and rate control.