Purpose The aim of the study was to evaluate the rate of ambulance use and the long-term prognosis in acute chest pain in an urban and a rural area and whether there is a difference between an urban and a rural area. Procedures Patients with acute chest pain consecutively admitted to Sahlgrenska University Hospital (a city hospital) and Uddevalla County Hospital between November 1996 and April 1997 were followed up prospectively for 5 years. Results In the city hospital, 688 (36%) of 1907 patients were transported by ambulance as compared with 369 (44%) of 842 patients in the county hospital. The patients transported by ambulance were much older (mean, 71 vs 59 years in both areas), and the comorbidity was more severe among patients transported by ambulance in both areas. In the city hospital, the 5-year mortality was 41.8% among those transported by ambulance and 15.8% among those transported by other means (P < .0001). The corresponding figures for the county hospital were 38.7% and 11.0% with a P value of less than .0001. Conclusions During the 1990s, patients with acute chest pain who were transported to a hospital by ambulance differed markedly in characteristics and outcome when compared with patients transported by other means. Results did not differ with regard to area.