The use of cardiovascular procedures has become routine in the management of acute myocardial infarction (MI). However, diagnostic testing beyond coronary revascularization procedures and use over time has not been well characterized. Records of 35- to 74-year-old adults hospitalized with MI in 4 US communities from 1987 to 2001 were abstracted using standardized data collection methods. Rates of procedure use and outcomes were compared by patient characteristics. Of 11,242 patients (mean age 61 years, 43% women, 22% black), angiography use increased substantially over time, echocardiography use increased more in women than men (interaction p<0.05), use of right-sided cardiac catheterization decreased, and use of nuclear scans and exercise tests remained constant. Men, whites, and locations with the highest angiography and right-sided cardiac catheterization use had lower noninvasive testing. In multivariate analysis, women had less angiograms and more echocardiograms obtained than men, but only in those with no previous MI before this hospitalization (both interaction p<0.05). Similarly, in those without previous MI, blacks were even less likely than whites to undergo angiography compared with those with a history of MI (interaction p=0.0001). Adjusted mortality rates were similar by gender, but mortality was higher in blacks than whites, a difference that decreased with adjustment for angiography use. In conclusion, in patients hospitalized with MI, use of many diagnostic cardiovascular procedures varied over time, with differences by gender, age, race, and geography that persisted over time unexplained by many measurable characteristics. There may also be continued perception of lower risk in women and blacks without a known diagnosis of MI.