Although not usually immediately life threatening, atrial fibrillation (AFib) poses a significant long-term risk to health. The best-documented and probably largest long-term risk in this condition is from thromboembolic complications, but this has been shown to be largely overcome by moderate intensity anticoagulation. In addition, however, AFib has significant detrimental effects on exercise capacity and overall quality of life, can cause or exacerbate heart failure, and imposes significant health-care burdens. Cardioversion, usually by transthoracic direct current shock, restores sinus rhythm in > 80% of patients, but recurrence of AFib over the weeks and months that follow decreases the value of this strategy. Antiarrhythmic drugs lessen the recurrence rate and add to the overall efficacy of achieving the treatment goal of restoring and maintaining sinus rhythm, rather than accepting permanent AFib with ventricular rate control and long-term thromboembolic prophylaxis. Whereas clear evidence exists that abolishing AFib makes patients feel better in the short-to-medium term, data on the economic viability or long-term efficacy of such a strategy are sparse. Management trials in AFib currently ongoing will provide some answers, but the decision as to whether restoring sinus rhythm is feasible and realistic in individual patients will remain a decision to be made on a case-by-case basis.