Pacemakers are mainly used for the treatment of patients with a heartbeat that is too slow. There are two types of pacemakers: permanent artificial pacemakers and temporary artificial pacemakers. Temporary pacemakers are only used for temporary emergencies, while we generally refer to permanent pacemakers. Currently, the main indication for a permanent pacemaker is still a slow heartbeat, which is often referred to as bradycardia in clinical practice. A permanent pacemaker should be implanted if a person’s heart stops for more than 3 seconds, or if the heart rate is often below 40 beats per minute at night and below 45 beats per minute during the day, especially if it is accompanied by symptoms such as dizziness, weakness and easy fatigue, palpitations, dark haze, or even syncope. What should be noted is whether symptoms such as dizziness are caused by a slow heartbeat or by bradycardia. Insomnia at night, chest tightness, and breath-holding should be first considered to be related to psychoneurological stimulation or neurosis due to the presence of mental stimulation. Although the ambulatory ECG showed a slowest heart rate of 42 beats per minute, it did not seem to be related to the patient’s symptoms. Therefore, for this woman, she should first adjust her mental status and add some sedative and anti-anxiety medications if necessary. If the palpitations and chest tightness persist after the mental symptoms have improved, then consider whether it is related to a too slow heart rate. It is important to note: Do not treat symptoms caused by a truly slow heartbeat as neurosis. Sometimes, symptoms caused by a too slow heartbeat or bradycardia are not well differentiated from neurosis. Generally speaking, neurosis mostly has mental stimulation or unpleasant factors, and often has insomnia and emotional instability in addition to palpitations, panic, chest tightness, and weakness. The symptoms caused by a slow heartbeat are mainly palpitations, chest tightness, fatigue, etc. These symptoms are more obvious at night, and sometimes get up and move around instead of getting better, because the activity can speed up the heartbeat of some patients and make the symptoms relieved. However, the psychological factors in these patients are not so obvious. There is also a group of patients who need pacemaker implantation who do not have slow heartbeat in quiet or sleep, but have palpitations, weakness, chest tightness, dizziness, and dark haze after activity. In these patients, the heart rate is normal in quiet situations, but it does not increase accordingly during activity, thus causing symptoms. In normal people, the volume of blood discharged from the heart can increase significantly with high activity, and the main reason for this increase is the acceleration of the heart rate, so the inability to accelerate the heart rate during exercise can produce significant symptoms. A permanent pacemaker with frequency adaptation (or frequency response) should also be considered for this group of patients, as it can automatically increase the pacing heart rate during exercise. Pacemaker technology has evolved rapidly in recent years, with a new generation of more advanced products being introduced almost every six months. Pacemakers used today are very small, weighing only 20 grams or so and are becoming more and more functional, some of them being highly intelligent and automatically controlling pacemaker functions. It is not only able to feel, but also to think and react immediately. For example, if there is a sudden atrial fibrillation, it will automatically close the part connected to the atria to protect the ventricles from being “involved”, and when the atrial fibrillation disappears and the normal heart rate is restored, it will open again on its own. Finally, I would like to discuss the pacemaker implantation procedure. Compared to other cardiac interventions, pacemaker implantation is relatively safe. It is usually performed by cutting or puncturing a large vein (usually the cephalic and subclavian veins), inserting the electrode lead into the heart cavity, selecting a suitable position and fixing it, then making a subcutaneous incision to make a capsule, connecting the pacemaker to the electrode lead and placing it in the capsule, suturing the skin, and removing the stitches a few days later. The procedure usually takes 1-2 hours.