Sick sinus syndrome, the significant clinical manifestation of progressive sinus node dysfunction, is the most frequent indication for the implantation of permanent pacing systems in the United States. Revolutionary advances in pacemaker hardware and programmability now allow a careful tailoring of device, mode, and program for the individual patient and underlying electrophysiologic abnormalities. Evidence indicates that appropriate mode selection in this group of patients not only ameliorates symptoms but may decrease the incidence of complications and help maintain an acceptable quality of life. Most available data is retrospective and uncontrolled, therefore controversy remains regarding mode recommendations. More conclusive data may be produced by clinical trials currently in progress. This article reviews the latest innovations and recommendations regarding permanent pacing for sick sinus syndrome.