Background Evidence of health disparities between urban and rural populations usually favors urban dwellers. The impact of rurality on heart failure (HF) outcomes is unknown. Objective We compared event-free survival between HF patients living in urban and rural areas. Methods In this longitudinal study, 136 patients with HF (male, 70%; age, mean ± SD 61 ± 11 years; New York Heart Association class III/IV, 60%) were enrolled. Patients' emergency department visits for HF exacerbation and rehospitalization during follow-up were identified. Rural status was determined by rural-urban commuting area code. Survival analysis was used to determine the effect of rurality on outcomes while controlling for relevant demographic, clinical, and psychosocial variables. Results Rural patients (64%) had longer event-free survival than urban patients (P = .015). Rurality (P = .04) predicted event-free survival after controlling for age, marital status, New York Heart Association class, medications, adherence to medications, depressive symptoms, and social support. Conclusions Rural patients were less likely than their urban counterparts to experience an event. Further research is needed to identify protective factors that may be unique to rural settings.