Two strategies for treatment of atrial fibrillation in the elderly include rate control with anticoagulation, or cardioversion and maintenance of sinus rhythm. Rate controlling agents include digoxin, calcium blockers, and b-blockers, most effective during exercise, or nonpharmacologic control with AV nodal ablation and pacemaker implantation. Agents to maintain sinus rhythm in the elderly include class Ia and III antiarrhythmics, with 1 year efficacies of approximately 50%. Whether the overall benefits of pharmacologic maintenance of sinus rhythm outweigh the risks of proarrhythmia and other adverse effects is under debate, but will be better delineated by the ongoing AFFIRM trial and VA cooperative trial, both randomizing patients to one of these two strategies.