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Current treatment guidelines for atrial fibrillation (AF) base decisions on the triad of prevention of symptoms and protection from stroke and tachycardia-mediated cardiomyopathy. Conceptually, all of these objectives could be satisfied by either timely cardioversion and subsequent rhythm control, or the admittedly easier (for the patient and the physician) rate control strategy. We feel strongly that pharmacological or electrical cardioversion is worth the effort and should in fact usher in a new paradigm for AF disease management, rather than the passive and defeatist approach currently in place.Response by Wyse on p 1443 AF is the most frequent arrhythmia in clinical practice and a major cause of morbidity and mortality.1 More than 100 years after Sir James Mackenzie first described a pulse irregularity associated with disappearance of the “a” wave from the jugular pulse and paralysis of the atria,2 the pathophysiology of AF remains incompletely understood. However, over the last half century it was realized that electrical, contractile, and structural remodeling are fundamental contributors to the disease process of AF, potentially allowing improved and more specific therapies. Traditional therapy for AF consists of empirically tested ion channel blockers, offered without a real understanding of the pathophysiologic basis of the disease. It is therefore not surprising that pharmacological therapies for AF are neither as effective nor as safe as we would like. In major clinical trails, which have traditionally based success on absence of symptoms alone, antiarrhythmic drugs (AADs) prevent recurrent AF in 50% to 65% over short-term follow-up. It is largely due to frustration from current AADs that studies comparing rate control with rhythm control were conducted. Although the debate of rhythm versus rate control continues, it is important to realize that with either therapy, mortality trends in patients with AF remained unabated. In a longitudinal cohort study …

Pharmacological and Electrical Conversion of Atrial Fibrillation to Sinus Rhythm Is Worth the Effort