The current evidence for pacemaker therapy is reviewed in 2 different syncopal conditions: reflex syncope with cardioinhibitory response and syncope in patients with bundle branch block. Although recent trials support the use of pacemaker therapy in selected patients with reflex syncope in whom an asystole is documented during spontaneous syncope or in whom an asystole is provoked with adenosine-5′-triphosphate administration, the best strategy in these patients and in those with syncope and bundle branch block is not well established. Ongoing clinical trials will answer this question.