Towards a consensus in rate versus rhythm control for management of atrial fibrillation: insights from the PIAF trial.

Knowledge on the pathophysiology of atrial fibrillation is rapidly expanding and identification of focally localized triggers have led to the development of new treatment options for this arrhythmia. Conversely, the clinical decision whether to restore and maintain sinus rhythm or simply control the ventricular rate has remained a matter of intense debate. The Pharmacological Intervention in Atrial Fibrillation (PIAF) trial was the first pilot-study to prospectively assess the symptomatic benefits of rate versus rhythm control in patients with persistent symptomatic AF. Since the publication of PIAF, results from three additional randomized clinical trials have confirmed and extended the PIAF notion of equivalent outcomes with regard to symptoms, quality of life, and cardiovascular events. This review summarizes the rationale and results of PIAF in an attempt to update and discuss the clinical relevance of these findings in the light of the other studies and with regard to individual treatment options.