{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T15:17:50Z","timestamp":1777475870215,"version":"3.51.4"},"reference-count":21,"publisher":"Springer Science and Business Media LLC","issue":"2","license":[{"start":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T00:00:00Z","timestamp":1774224000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T00:00:00Z","timestamp":1774224000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100007109","name":"Universit\u00e0 degli Studi di Ferrara","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100007109","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100007109","name":"Universit\u00e0 degli Studi di Ferrara","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100007109","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["CURR MED SCI"],"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Atrial fibrillation (AF) is a frequent arrhythmia in sepsis patients and is traditionally regarded as a harmful epiphenomenon requiring immediate correction. Its abrupt onset and association with adverse outcomes have driven clinicians to pursue aggressive rhythm or rate control strategies, which are often extrapolated from cardiology rather than sepsis-specific evidence. However, emerging data challenge this reflexive approach. Studies with ultrashort-acting beta-blockers, such as esmolol and landiolol, have shown that hemodynamic stabilization may occur even in the absence of sinus rhythm restoration. This raises a provocative question: could AF during sepsis represent not a pathological disturbance but rather a transient and potentially tolerable manifestation of sepsis-related cardiovascular stress? We propose the concept of \u201cpermissive AF,\u201d shifting the focus from rhythm restoration to hemodynamic optimization and organ perfusion. Thus, AF is not framed as a physiological adaptation per se but as a maladaptive manifestation of sepsis-related cardiac injury that may be clinically tolerated, paralleling permissive strategies in critical care, such as permissive hypercapnia or restrictive transfusion thresholds. This does not imply therapeutic inaction; rather, it is a goal-directed approach that tolerates arrhythmia when adequate rate control and perfusion are achieved. This paradigm challenges established clinical instincts and underscores the need for individualized management. Recognizing AF as a potential adaptive rhythm reframes research priorities: identifying biomarkers of atrial inflammation, stratifying patients according to hemodynamic impact, and testing permissive versus corrective strategies in prospective trials. The permissive AF strategy proposed herein is expected to foster patient-centered care and reduce iatrogenic harm in the complex interplay between sepsis and the heart.<\/jats:p>\n                  <jats:p>\n                    <jats:bold>Graphical Abstract<\/jats:bold>\n                  <\/jats:p>\n                  <jats:p>Clinical dilemma of atrial fibrillation during sepsis. Electrical cardioversion is depicted with traditional defibrillator pads, symbolizing rhythm-focused intervention (left). Pharmacologic rate control is represented by beta-blockers and a perfused heart, highlighting a patient-centered approach on the basis of hemodynamic stability (right).<\/jats:p>","DOI":"10.1007\/s11596-026-00185-w","type":"journal-article","created":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T07:35:15Z","timestamp":1774251315000},"page":"277-282","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["What If We Let It Fibrillate? New Perspective on Atrial Fibrillation in Sepsis"],"prefix":"10.1007","volume":"46","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5841-8555","authenticated-orcid":false,"given":"Matteo","family":"Guarino","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roberto","family":"De Giorgio","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2026,3,23]]},"reference":[{"issue":"6","key":"185_CR1","doi-asserted-by":"publisher","first-page":"949","DOI":"10.1016\/j.ahj.2013.03.020","volume":"165","author":"AJ Walkey","year":"2013","unstructured":"Walkey AJ, Greiner MA, Heckbert SR,\u00a0et\u00a0al. Atrial fibrillation among Medicare beneficiaries hospitalized with sepsis: incidence and risk factors. Am Heart J. 2013;165(6):949\u2013955.e3.","journal-title":"Am Heart J."},{"issue":"2","key":"185_CR2","doi-asserted-by":"publisher","first-page":"205","DOI":"10.1164\/rccm.201603-0618OC","volume":"195","author":"PMC Klein Klouwenberg","year":"2017","unstructured":"Klein Klouwenberg\u00a0PMC, Frencken JF, Kuipers S,\u00a0et\u00a0al. Incidence,\u00a0predictors, and\u00a0outcomes of\u00a0new-onset\u00a0atrial\u00a0fibrillation in\u00a0critically\u00a0ill\u00a0patients with\u00a0sepsis.\u00a0a\u00a0cohort\u00a0study. Am J Respir Crit Care Med. 2017;195(2):205\u2013211.","journal-title":"Am J Respir Crit Care Med."},{"issue":"9","key":"185_CR3","doi-asserted-by":"publisher","first-page":"840","DOI":"10.1056\/NEJMra1208623","volume":"369","author":"DC Angus","year":"2013","unstructured":"Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med. 2013;369(9):840\u2013851.","journal-title":"N Engl J Med."},{"issue":"5","key":"185_CR4","doi-asserted-by":"publisher","first-page":"1138","DOI":"10.1378\/chest.14-0986","volume":"146","author":"YC Lau","year":"2014","unstructured":"Lau YC, Lip GYH. Atrial fibrillation during sepsis: a determinant of long-term outcomes?\u00a0Chest. 2014;146(5):1138\u20131140.","journal-title":"Chest."},{"issue":"6","key":"185_CR5","doi-asserted-by":"publisher","first-page":"1424","DOI":"10.1016\/j.chest.2018.03.040","volume":"154","author":"NA Bosch","year":"2018","unstructured":"Bosch NA, Cimini J, Walkey AJ. Atrial\u00a0fibrillation in the ICU. Chest. 2018;154(6):1424\u20131434.","journal-title":"Chest."},{"issue":"7","key":"185_CR6","first-page":"378","volume":"46","author":"A Briva","year":"2010","unstructured":"Briva A, Lecuona E, Sznajder JI. Hipercapnia permisiva o no permisiva: mecanismos de acci\u00f3n y consecuencias de\u00a0Altos niveles de di\u00f3xido de carbono.\u00a0Arch\u00a0De Bronconeumolog\u00eda. 2010;46(7):378\u2013382.","journal-title":"Arch De Bronconeumolog\u00eda."},{"issue":"5","key":"185_CR7","doi-asserted-by":"publisher","first-page":"748","DOI":"10.21037\/jtd.2016.03.58","volume":"8","author":"HW He","year":"2016","unstructured":"He HW, Liu DW. Permissive hypoxemia\/conservative oxygenation strategy: Dr. Jekyll or Mr. Hyde?\u00a0J Thorac Dis. 2016;8(5):748\u2013750.","journal-title":"J Thorac Dis."},{"issue":"6","key":"185_CR8","doi-asserted-by":"publisher","first-page":"2049","DOI":"10.3390\/jcm14062049","volume":"14","author":"DA Jim\u00e9nez Franco","year":"2025","unstructured":"Jim\u00e9nez Franco DA, P\u00e9rez Vel\u00e1squez CA, Rodr\u00edguez Lima DR. Mortality in\u00a0critically\u00a0ill\u00a0patients with\u00a0liberal\u00a0versus\u00a0restrictive\u00a0transfusion\u00a0thresholds:\u00a0a\u00a0systematic\u00a0review and\u00a0meta-analysis of\u00a0randomized\u00a0controlled\u00a0trials with\u00a0trial\u00a0sequential\u00a0analysis. J Clin Med. 2025;14(6):2049.","journal-title":"J Clin Med."},{"issue":"9","key":"185_CR9","doi-asserted-by":"publisher","first-page":"1064","DOI":"10.1111\/j.1540-8167.2010.01774.x","volume":"21","author":"P Patel","year":"2010","unstructured":"Patel P, Dokainish H, Tsai P,\u00a0et\u00a0al. Update on the association of inflammation and atrial fibrillation. J Cardiovasc Electrophysiol. 2010;21(9):1064\u20131070.","journal-title":"J Cardiovasc Electrophysiol."},{"key":"185_CR10","volume":"2014","author":"M Arrigo","year":"2014","unstructured":"Arrigo M, Bettex D, Rudiger A. Management of atrial fibrillation in critically ill patients. Crit Care Res Pract. 2014;2014:840615.","journal-title":"Crit Care Res Pract."},{"issue":"16","key":"185_CR11","doi-asserted-by":"publisher","first-page":"1683","DOI":"10.1001\/jama.2013.278477","volume":"310","author":"A Morelli","year":"2013","unstructured":"Morelli A, Ertmer C, Westphal M,\u00a0et\u00a0al. Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: a randomized clinical trial. Jama. 2013;310(16):1683.","journal-title":"Jama."},{"issue":"10","key":"185_CR12","doi-asserted-by":"publisher","first-page":"1622","DOI":"10.1007\/s00134-024-07587-1","volume":"50","author":"S Rehberg","year":"2024","unstructured":"Rehberg S, Frank S,\u00a0\u010cern\u00fd\u00a0V,\u00a0et\u00a0al. Landiolol for heart rate control in patients with septic shock and persistent tachycardia. A multicenter randomized clinical trial (Landi-SEP).\u00a0Intensive Care Med. 2024;50(10):1622\u20131634.","journal-title":"Intensive Care Med."},{"issue":"9","key":"185_CR13","doi-asserted-by":"publisher","first-page":"863","DOI":"10.1016\/S2213-2600(20)30037-0","volume":"8","author":"Y Kakihana","year":"2020","unstructured":"Kakihana Y, Nishida O, Taniguchi T,\u00a0et\u00a0al. Efficacy and safety of landiolol, an ultra-short-acting \u03b21-selective antagonist, for treatment of sepsis-related tachyarrhythmia (J-Land 3S): a multicentre, open-label, randomised controlled trial. Lancet Respir Med. 2020;8(9):863\u2013872.","journal-title":"Lancet Respir Med."},{"issue":"10","key":"185_CR14","doi-asserted-by":"publisher","first-page":"2951","DOI":"10.3390\/jcm13102951","volume":"13","author":"B Levy","year":"2024","unstructured":"Levy B, Slama M, Lakbar I,\u00a0et\u00a0al. Landiolol for\u00a0treatment of\u00a0new-onset\u00a0atrial\u00a0fibrillation in\u00a0critical\u00a0care:\u00a0a\u00a0systematic\u00a0review. J Clin Med. 2024;13(10):2951.","journal-title":"J Clin Med."},{"issue":"19","key":"185_CR15","doi-asserted-by":"publisher","first-page":"1368","DOI":"10.1056\/NEJMoa010307","volume":"345","author":"E Rivers","year":"2001","unstructured":"Rivers E, Nguyen B, Havstad S,\u00a0et\u00a0al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368\u20131377.","journal-title":"N Engl J Med."},{"issue":"9","key":"185_CR16","doi-asserted-by":"publisher","first-page":"1653","DOI":"10.1007\/s00134-013-2998-5","volume":"39","author":"B Vallet","year":"2013","unstructured":"Vallet B, Pinsky MR, Cecconi M. Resuscitation of patients with septic shock: please\u00a0\u201cmind the gap\u201d! Intensive Care Med. 2013;39(9):1653\u20131655.","journal-title":"Intensive Care Med."},{"issue":"6","key":"185_CR17","doi-asserted-by":"publisher","first-page":"1110.e1","DOI":"10.1016\/j.jcrc.2013.07.049","volume":"28","author":"W Du","year":"2013","unstructured":"Du W, Liu DW, Wang XT,\u00a0et\u00a0al. Combining central venous-to-arterial partial pressure of carbon dioxide difference and central venous oxygen saturation to guide resuscitation in septic shock. J Crit Care. 2013;28(6):1110.e1\u20131110.e5.","journal-title":"J Crit Care."},{"issue":"9","key":"185_CR18","doi-asserted-by":"publisher","first-page":"3188","DOI":"10.3390\/jcm12093188","volume":"12","author":"M Guarino","year":"2023","unstructured":"Guarino M, Perna B, Cesaro AE,\u00a0et\u00a0al. 2023\u00a0update on\u00a0sepsis and\u00a0septic\u00a0shock in\u00a0adult\u00a0patients:\u00a0management in the\u00a0emergency\u00a0department. J Clin Med. 2023;12(9):3188.","journal-title":"J Clin Med."},{"issue":"7","key":"185_CR19","doi-asserted-by":"publisher","first-page":"793","DOI":"10.1161\/CIRCULATIONAHA.106.678359","volume":"116","author":"MW Merx","year":"2007","unstructured":"Merx MW, Weber C. Sepsis and the heart. Circulation. 2007;116(7):793\u2013802.","journal-title":"Circulation."},{"issue":"11","key":"185_CR20","doi-asserted-by":"publisher","first-page":"2784","DOI":"10.1016\/j.hrthm.2025.02.040","volume":"22","author":"L Bianchini","year":"2025","unstructured":"Bianchini L, Tramujas L, Besen BAMP,\u00a0et\u00a0al. Anticoagulation in critically ill patients with new-onset atrial fibrillation: Insights from a retrospective cohort study.\u00a0Heart Rhythm. 2025;22(11):2784\u20132790.","journal-title":"Heart Rhythm."},{"key":"185_CR21","doi-asserted-by":"publisher","DOI":"10.62675\/2965-2774.20250120","volume":"37","author":"C Teixeira","year":"2025","unstructured":"Teixeira C, Tonietto TF. The quandary of anticoagulation for sepsis patients with new-onset atrial fibrillation. Crit Care Sci. 2025;37:e20250120.","journal-title":"Crit Care Sci."}],"container-title":["Current Medical Science"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11596-026-00185-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s11596-026-00185-w","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11596-026-00185-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T13:54:25Z","timestamp":1777384465000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s11596-026-00185-w"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,23]]},"references-count":21,"journal-issue":{"issue":"2","published-print":{"date-parts":[[2026,4]]}},"alternative-id":["185"],"URL":"https:\/\/doi.org\/10.1007\/s11596-026-00185-w","relation":{},"ISSN":["2096-5230","2523-899X"],"issn-type":[{"value":"2096-5230","type":"print"},{"value":"2523-899X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,23]]},"assertion":[{"value":"31 July 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 March 2026","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"5 March 2026","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"23 March 2026","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The Authors declare that they have no conflict of interest.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of Interests"}},{"value":"This research does not directly involve patients; hence, ethical approval was deemed unnecessary.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical Approval and Consent to Participate"}},{"value":"Not applicable.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for Publication"}}]}}