[In recurrent atrial fibrillation should a sinus rhythm always try to be maintained? No. What are the therapeutic alternatives?].

Despite the high incidence of atrial fibrillation, and the morbidity and mortality associated with this arrhythmia, we are still not sure of the best strategy to deal with it. There is little comparative data between the two strategies most often used: cardioversion and prophylactic antiarrhythmics to maintain sinus rhythm; or pharmacological control of ventricular rate and antithrombotic drugs. The first strategy seems to be the most desirable, but there are two arguments against its use in all patients: 1. It is not indicated when the probability of maintaining sinus rhythm during a sufficiently long period of time is poor. This is case of premature recurrence despite several long course atrial fibrillation treatments (more than one year), and the presence of a very large left atrium. 2. It is not indicated when the advantages of maintaining sinus rhythm do not outweigh its pitfalls. These are mainly related to the use of antiarrhythmic drugs, the efficacy of which is not very great and may present a potential risk of lethal pro-arrhythmia or severe collateral effects. The alternative strategy is feasible with the use of less toxic drugs and the high efficacy and safety of anticoagulant therapy for the prevention of thromboembolic events is currently known. Therefore, we are able to achieve a reasonable control of patient symptoms with a low risk of serious incidents. Trials comparing these strategies have not yet been concluded, therefore therapy must be individualised and based on a correct evaluation of foreseeable risks and benefits.