Atrial fibrillation is the commonest sustained tachyarrhythmia encountered in clinical practice.1 With an ageing population and improved survival of patients with cardiac disease its prevalence continues to rise.2 It is associated with a doubling of overall morbidity and mortality from cardiovascular disease3 and is the most common cause of embolic stroke.4 Restoring sinus rhythm holds the theoretical advantage of reducing the risk of thromboembolism and need for anticoagulation and improved haemodynamics and quality of life. However, most current anti-arrhythmic drugs have limited efficacy and several side effects. With the use of anti-arrhythmics and serial electrical cardioversion for early relapse up to 53% of patients are in sinus rhythm at one year,5 but only 25% remain so at five years.6 Considerable controversy therefore exists as to whether rhythm or rate control is the more appropriate management for most patients with persistent atrial fibrillation. Five recent trials have looked specifically at this issue.

The PIAF study was the first randomised published …