With increasing age, the incidence of symptomatic bradyarrhythmia increases and often the implantation of a pacemaker is necessary. Acute drug treatment (or discontinuation of potentially causative drugs) is suitable for short-term stabilization of the patient in the acute situation but ultimately rarely prevents the need for a pacemaker. Today’s timely management consists of avoiding temporary pacemaker therapy (with the exception of special situations such as myocardial infarction and percutaneous aortic valve replacement) and ideally implanting the required pacemaker as part of a single procedure even outside normal treatment times. It is essential to make a clear primary diagnosis in order to ensure an individual personalized approach regarding the optimal device choice (pacemaker, ICD, and CRT) and programming as well as long-term planning of device changes.