Modern pacemaker technology renders possible the adaptation of pacing rate to hemodynamic requirements. The most ambitious approach aims at restoration of the physiological closed-loop system by utilizing the information supplied by the autonomic nervous system (ANS) and extracted from myocardial contractile performance. Measurement is accomplished by the impedance method using the stimulation electrode as the measuring electrode. The ventricular inotropic parameter (VIP) has been identified as an ANS dependent parameter. A special detection algorithm, regional effective slope quantity (RQ), with high ANS sensitivity has been developed. Rate adaptation has been achieved by using an individually adjustable inotropic index (II). The concept has been evaluated in a multicenter study using a standardized exercise protocol. The results in patients with AV block demonstrate excellent agreement between spontaneous sinus rhythm and the ANS-controlled stimulation rate during different forms of exercise. Measurement of mean arterial blood pressure (MABP) supports the physiological approach of adapting the pacing rate to various types of hemodynamic challenges.