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Both sides of the debate on whether to control rhythm or rate agree that sinus rhythm is better than atrial fibrillation.1 If a strategy to control rhythm could guarantee to be efficacious, cost effective, and have no risk of adverse events, there would be no argument. Unfortunately, this is rarely the case. Rhythm control is difficult to achieve and initially requires the use of potentially toxic drugs. If the objective is to “first do no harm,” rate control is more important.MortalitySix randomised controlled trials comparing rate and rhythm control have clearly shown that mortality (whether as a primary or composite end point) is not reduced with rhythm control.2 3 4 5 6 7 In the two largest of these there was even a trend to increased mortality in the rhythm control group.3 4 This is probably because of the potential toxicity of rhythm control drugs and the inappropriate withdrawal of warfarin

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