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Atrial fibrillation is an increasingly common arrhythmia which is associated with a substantial burden of cardiovascular disease. The arrhythmia is mostly treated with pharmacological therapy, although some interventional techniques such as left atrial ablation, atrioventricular nodal ablation plus pacemaker implantation, and left atrial appendage occlusion or excision are gaining popularity. The concept of primary prevention of atrial fibrillation with therapies targeting the formation and progression of atrial substrate has also recently evolved. Medical treatment is directed at either rate control (slowing the ventricular rate and allowing atrial fibrillation to continue) or rhythm control (restoring and maintaining sinus rhythm). There are different types of therapy for each purpose. Antiarrhythmic drug therapy, however, is difficult and inadequate with the agents that are now available. Treatment may be ineffective or complicated by cardiac or extracardiac adverse effects. Guidelines exist to help physicians choose appropriate therapies, but they have required and continue to need revision to cope with the rapid development and accumulating experience with new treatments. This review provides a contemporary evidence-based insight into the medical management of atrial fibrillation in the modern era.