Acute myocardial infarction (AMI) is an important condition cared for in rural hospitals. Most recommended interventions require no sophisticated technology and should be available in rural and urban hospitals. This study examined the quality of AMI care in rural hospitals. It was a cohort study using data from the 1994 and 1995 Centers for Medicare & Medicaid Services’ Cooperative Cardiovascular Project and the 1995 American Hospital Association’s Annual Survey of Hospitals. The study included U.S. acute-care hospitals caring for patients with AMI, and Medicare beneficiaries ages 65 and older directly admitted to four types of acute-care hospitals–remote small rural, small rural, large rural, and urban–for a confirmed AMI between 1994 and 1995. Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive recommended AMI treatments. Medicare patients treated in rural hospitals were less likely than urban hospitals’ patients to receive aspirin during hospitalization or at discharge, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only one treatment–ACE inhibitors at discharge–was used more for patients in rural hospitals. Medicare patients in rural hospitals had significantly higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals. Efforts are needed to help hospital medical staffs, especially those in rural areas, develop systems to ensure that patients receive recommended AMI treatments. Funded by HRSA’s ORHP.