Bradycardia and permanent pacemakers

Permanent cardiac pacing remains the only effective treatment for symptomatic bradyarrhythmia. Recent technological advances have refined the ability of pacemakers to mimic physiological cardiac conduction. Sophisticated algorithms optimizing rate response and minimizing ventricular pacing are improving clinical outcomes. Increasingly, pacemakers are being used beyond the realm of rhythm management, with biventricular pacing now a well-established treatment modality for drug-refractory heart failure. We review the pathophysiology of bradyarrhythmias and discuss the investigation and management of this common clinical problem.