Pacemaker procedures performed at the Mayo Clinic for the years 1961, 1971, and 1981 were reviewed to examine the changes that have occurred in a large pacemaker practice during the 2 decades since the advent of pacemaker therapy. Major changes in trends and practice have occurred; in addition to numerical growth, the indications for permanent pacing and the technologic alternatives available have expanded considerably. The increasing choices available today (in all areas of pacemaker practice) provide a challenging stimulus to physicians as they seek the best clinical options in patient care.