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The possible mechanisms that account for the beneficial response seen with L-carnitine in AMI are probably multifactorial and include, in part, an improvement in myocardial mitochondrial energy metabolism in the heart due to its ability to enhance the transport of long-chain fatty acids from the cytosol to the mitochondrial matrix where -oxidation occurs, removing toxic fatty acid intermediates, lessening ischemia secondary to elevated long-chain fatty acid concentrations, and replenishing the depleted carnitine concentrations seen in ischemic, infarct, and failing myocardium

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From the evolutionary perspective, the formation of the unusual D-malate intermediate prevents the direct channeling of malate into the TCA cycle which requires the presence of one further enzyme (MDH)

Acetyl-L-carnitine (ALCAR) has been reported to increase agitation in some Alzheimer's disease patients (133)