With the tremendous advances in cardiac pacing during the past four decades, cardiac pacemaker implantation is now a common clinical procedure. In recent years, the indications for permanent pacemakers have expanded. This increase in reasons for pacing and shift in mode of pacing have been caused by the evolution of pacemaker therapy from a life-saving measure (mortality), to one aimed at improving health-related quality of life (HRQoL). Until now the efficacy of pacing therapy has predominantly been measured using "objective" criteria. However, in recent years the importance of HRQoL as an outcome measure has increasingly been recognized as patients prefer quality over quantity of life. In this review we describe the development and testing of Aquarel, a new developed HRQoL questionnaire for pacemaker patients, composed of a generic core module with disease specific add-ons. Current and future research to improve the Aquarel questionnaire is also described.