Rate or rhythm control in persistent atrial fibrillation?

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia encountered in clinical practice, with the majority of patients aged > 65 years. With an increasingly ageing population, the burden of AF in society continues to rise. One of the principal controversies in AF management is whether to control the ventricular rate and accept the underlying rhythm, or to attempt to achieve sinus rhythm. Until recently there were no clinical trial data directly comparing a rate versus rhythm strategy, and most physicians have opted for rhythm control, based on its theoretical benefits. We present an up-to-date evidence-based overview of the relative merits of rate versus rhythm control in AF, including data from five recent randomized trials. We draw conclusions from these studies and present evidence-based guidance on when to adopt which approach in routine clinical practice.