An observational cohort study examined the difference in use of cardiac procedures during and after hospital admission for acute chest pain in 47 metropolitan or non-metropolitan hospitals across New South Wales (NSW). There were 3836 patients, represented by 4151 admissions to hospital after acute myocardial infarction (AMI), unstable angina or other angina. Follow up at 22 months was completed on 1695 patients. Patients admitted to metropolitan hospitals had higher rates of most cardiac procedures while in-patients than did patients in non-metropolitan hospitals. Odds ratios (95% confidence intervals) for the use of exercise stress tests, echocardiograms, nuclear studies and coronary angiography were 3.30 (1.38, 7.90), 9.34 (4.07, 21.44), 4.87 (2.08, 11.39) and 68.64 (17.29, 272.49), respectively, for patients with AMI and 1.93 (0.91, 4.12), 5.60 (1.60, 19.57), 3.51 (1.48, 8.33) and 38.57 (9.36, 158.94), respectively, for patients with unstable angina. Rates were similar between hospital types during the 22 months after discharge. The appropriateness of this large variation in resource use between metropolitan and non-metropolitan hospitals requires examination.