Background Symptom-focused management is one of the cornerstones of optimal atrial fibrillation (AF) therapy. Objectives To evaluate the use of rhythm control and rate control strategy. Second, to identify predictors of the use of amiodarone in patients with rhythm control and of the use of rhythm control strategy in patients with paroxysmal AF in the Balkans. Methods Prospective enrolment of consecutive patients from 7 Balkan countries to the BALKAN-AF survey was performed. Results Of 2,712 enrolled patients, 2,522 (93.0%) with complete data were included: 1,622 (64.3%) patients were assigned to rate control strategy and 900 (35.7%) to rhythm control. Patients with rhythm control were younger, more often hospitalized for AF and with less comorbidities (all p <0.05) than those with rate control. Symptom score [European Heart Rhythm Association (EHRA)] was not an independent predictor of a rhythm control strategy [odds ratio (OR) 0.99, 95% confidence interval (CI) 0.90-1.10, p = 0.945]. The most commonly chosen antiarrhythmic agents were amiodarone (49.7%), followed by propafenone (24.3%). Conclusion More than one third of patients in BALKAN-AF survey received a rhythm control strategy, and these patients tended to be younger with less comorbidities than those managed with rate control. EHRA symptom score is not significantly associated with rhythm control strategy. The most commonly used antiarrhythmic agents were amiodarone, followed by propafenone.