The Challenges: Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors. The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations, and people with known CVD have increased morbidity and mortality from coronavirus disease 2019 (COVID-19). In addition, COVID-19 is associated with serious cardiac manifestations, potentially placing additional demand on limited regional services at a time of diminished visiting metropolitan support with restricted travel. Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity. Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic. Main Recommendations: Health districts, cardiologists and government agencies need to minimise impacts on the already vulnerable cardiovascular health of regional and remote Australians and New Zealanders throughout the COVID-19 pandemic. Changes in management should include: • Improved access to telehealth consultation for regional and rural outpatients. Specialist-led 24/7 electrocardiograph (ECG) reading and acute cardiology services, uniformly covering all rural inpatients, to minimise potential impacts on acute care. • Transfer models incorporating discussion between clinicians and ambulance, balancing urgency with considerations of ambulance capacity in rural locations. • Protection of the role of specialist cardiovascular nurses, avoiding COVID-19 redeployment to maintain rural cardiac service capacity. • An urgent shift to regional models for pacing services, utilising remote monitoring supported by local device implantation and local technicians. © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)