Background: In the mid-1990s, significant gaps existed in the quality of acute myocardial infarction (AMI) care between rural and urban hospitals. Since then, overall AMI care quality has improved. This study uses more recent data to determine whether rural-urban AMI quality gaps have persisted. Methods: Using inpatient records data for 34,776 Medicare beneficiaries with AMI from 2000-2001, unadjusted and logistic regression analysis compared receipt of 5 recommended treatments between admissions to urban, large rural, small rural, and isolated small rural hospitals as defined by Rural Urban Commuting Area codes. Results: Substantial proportions of hospital admissions in all areas did not receive guideline-recommended treatments (eg, 17.0% to 23.6% without aspirin within 24 hours of admission, 30.8% to 46.6% without beta-blockers at arrival/discharge). Admissions to small rural and isolated small rural hospitals were least likely to receive most treatments (eg, 69.2% urban, 68.3% large rural, 59.9% small rural, 53.4% isolated small rural received discharge beta-blocker prescriptions). Adjusted analyses found no treatment differences between admissions to large rural and urban area hospitals, but admissions to small rural and isolated small rural hospitals had lower rates of discharge prescriptions such as aspirin and beta-blockers than urban hospital admissions. Conclusions: Many simple guidelines that improve AMI outcomes are inadequately implemented, regardless of geographic location. In small rural and isolated small rural hospitals, addressing barriers to prescription of beneficial discharge medications is particularly important. The best quality improvement practices should be identified and translated to the broadest range of institutions and providers.