We report our experience of 20 patients who have had permanent pacemakers implanted for the first time after the age of 90. The main indications were syncope or presyncope which occurred in 15 patients. Complete heart block was present in 14 patients. Syncopal and presyncopal symptoms were cured in 73%. Nonagenarians paced for complete heart block can expect to survive for as long as others of the same age without heart block. Permanent pacing is an effective and appropriate treatment in the very old.