[Smart decisions in rhythmology : What should we know? What should be do? What do we still have to learn?]

Heart rhythm disorders are one of the most common cardiac problems in Germany. Every year, about 95,000 ablation procedures, 42,000 implantable cardioverter-defibrillators (ICD) and 102,000 pacemaker implantations are performed with the annual numbers continuing to increase. Besides technological innovations in the field of therapeutic devices (e.g., ablation tools), there are fundamental changes in the diagnostic workup for arrhythmias since smartwatches and wearable devices are increasingly available on the market. In this article, an overview on the latest developments in the field of invasive electrophysiology and rhythmology is provided. The following are explained: why electrocardiograms (ECGs) from smartwatches/wearables are usually of good quality and can be used for screening or confirmation of a diagnosis; why we should consider re-establishment of sinus rhythm in patients with atrial fibrillation or limited left ventricular function; to what extent investigator and center experience influence patient safety; how we can induce a physiological contraction pattern in about 70% of AV block patients by direct stimulation of the specific conduction system, why the benefit of an implantable ICD is questionable in nonischemic cardiomyopathy and ejection fraction (EF) <35 %; and finally, why cardiomyopathies induced by ventricular extrasystoles (VES) are so difficult to predict.