OBJECTIVE: To compare the use of medications in African-American and Caucasian elderly Medicare patients hospitalized with acute myocardial infarction (AMI) in Alabama. DESIGN: Retrospective medical record review. SETTING: All acute care hospitals in Alabama. PATIENTS: All Medicare patients with a principal discharge diagnosis of AMI from June 1992 through February 1993. We excluded those patients less than 65 years of age and those of ethnicity other than African-American or Caucasian (N = 4,052). MEASUREMENTS: We first performed a crude analysis using all cases to compare by race the use of thrombolysis, β-adrenergic blockade, and aspirin in the setting of AMI. In addition, we developed a multivariable model with receipt of therapy as the outcome and demographics, severity of illness, comorbidity, and algorithm-determined candidacy for therapy as covariates. The algorithms, developed as part of the Cooperative Cardiovascular Project, were designed to identify an 'ideal' pool of candidates for each therapy. MAIN RESULTS: For all eases, 9.2% (95% confidence interval [CI] 6.8, 12.1) of African Americans received thrombolysis compared with 17.3% (95% CI 16.0, 18.6) of Caucasians. Approximately 16.4% of patients received β-adrenergic blockade, and 45.1% received aspirin, both with no racial difference. By multivariate analysis, the adjusted odds ratio for African Americans receiving thrombolysis was 0.55 (95% CI 0.41, 0.76). The corresponding odds ratio was 1.25 (95% CI 0.99, 1.59) for β-adrenergic blockade and 1.13 (95% CI 0.96, 1.37) for aspirin. African Americans presented later after the onset of chest pain, but the refusal rate of thrombolytic therapy did not differ. CONCLUSIONS: According to this analysis, Alabama physicians used β-adrenergic blockade and aspirin equivalently in African Americans and Caucasians, African Americans received thrombolysis less often according to the crude analysis. The multivariable analysis suggests less use of thrombolytics, even after adjusting for several covariates including indication by clinical algorithm. However, the small number of African-American patients deemed ideal candidates for thrombolysis attenuates the precision of this finding.