Background: Current evidence shows inequality in the outcomes of rural and urban patients treated at their place of residence. This study compared in-hospital mortality between rural and urban patients with acute coronary syndrome (ACS) to find whether there were differences in the outcome and received treatment. Methods: Between May 2007 and January 2018, patients admitted with ACS were included. The patients’,demographic, clinical, and laboratory data, as well as their in-hospital medical courses, were recorded. The association between place of residence (rural/ urban) and in-hospital mortality due to ACS was evaluated using logistic regression adjusted for potential confounders. Results: Of 9088 recruited patients (mean age =61. 30±, 12. 25 y,5557 men [61. 1%]), 838 were rural residents. A positive family history of coronary artery disease (P=0. 003), smoking (P=0. 002), and hyperlipidemia (P=0. 026), as well as a higher body mass index (P=0. 013), was seen more frequently in the urban patients, while the rural patients had lower education levels (P<0. 001) and higher unemployment rates (P=0. 009). In-hospital mortality occurred in 135 patients (1. 5%): 10 rural (1. 2%) and 125 urban (1. 5%) patients (P=0. 465). The Firth regression model, used to adjust the effects of possible confounders, showed no significant difference concerning in-hospital mortality between the rural and urban patients (OR, 1. 57,95% CI, 0. 376 to 7. 450,P=0. 585). Conclusion: This study found no significant differences in receiving proper treatment and in-hospital mortality between ru-ral and urban patients with ACS.