Approximately 350,000 people in Canada are known to have atrial fibrillation (AF)- a serious but often-undetected cardiac arrhythmia characterized by uncoordinated and erratic atrial activity. AF is the most common sustained arrhythmia and is associated with very high increases in death and disability, including a 500% increase in stroke risk. AF is rising at an unprecedented rate due to the compounding effects of three of our largest health challenges: the aging population, chronic disease and obesity. The burden of this growth on urban parts of Canada will be great, however, effects on rural Canada will be profound due to the rapidly aging population in Canada’s rural communities, increased incidence of chronic disease, poorest health outcomes, and more limited capacity of rural health systems. In rural communities, AF is predominantly managed outside the hospital with limited resources. However, the majority of clinical guidelines for AF assume that services are provided in large urban centres. Services for rural and northern Canada are, by comparison, very scarce, and further research in this area is urgently needed. To understand these challenges further, we undertook a qualitative study with primary care providers in rural and northern Alberta and British Columbia. Telephone interviews with a purposive sample of 18 primary care providers were undertaken to explore both the experiences of managing AF and enacting clinical guidelines in rural and northern settings. Analysis of the data revealed that healthcare providers saw AF as a manageable condition, but that challenges existed due to limited access to specialist services, the hurdles and obstacles of patient monitoring, high workloads, poor patient literacy, and a lack of integration between the healthcare agencies managing AF. Activities addressing stroke prevention were considered most burdensome, particularly in relation to communication around stroke risk and the initiation and management of oral anticoagulation therapy. Vulnerable patients, such as transient workers and those with poor compliance, created significant challenges and often required physicians to delineate clinical recommendations in light of complex socioeconomic factors. Throughout the research, a range of innovative approaches to health care delivery were identified, including the use of telemedicine, expanded provider roles, and integrated approaches to patient education. This research has identified significant challenges faced by rural primary care providers when managing AF and enacting clinical guidelines. Understanding these challenges is critical to developing health care services that are responsive to the needs of the high risk and underserved rural populations.