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The role of pacemaker therapy for vasovagal syncope (VVS) is still controversial. The ISSUE 3 study led to reappraisal of pacing therapy (using DDD pacing with the rate-drop response algorithm) for reducing syncope recurrence in a highly selected patient group (age, ≥40 years) with asystolic VVS clinically documented by implantable loop recorder. However, the role of pacemaker treatment for young (age, <40 years) VVS patients remains to be established. Psychological sequelae and the burden of the long-term implanted device should be considered. DDD pacing with closed-loop stimulation seems to be a promising algorithm; however, we need more data to determine the best pacing algorithm. Multicenter, prospective mega trials with a randomized and controlled design are needed to resolve these issues.