The geographical distribution of mortality from ischaemic heart disease in the Netherlands has changed dramatically since 1950. In 1950-1954 mortality was highest in high-income, urbanized areas, in 1980-1984 the reverse was true. This development resembles the one observed in the United States of America. The changes in geographical distribution cannot be attributed to differences in cause-of-death certification. The change in the association with income and the association between mortality and a number of ischaemic heart disease risk factors found in 1970-1974, suggest that at least part of the explanation is a change in the geographical distribution of risk factors.