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Cardiac arrest occurs when the heart suddenly ceases to pump blood around the body. To optimise survival from out-of-hospital cardiac arrest (OHCA), knowledge of the spatial distribution of OHCA and the availability of resuscitation, or ‘Chain of Survival’, is required. Thus, this study aims to describe OHCA incidence and Chain of Survival availability in a manner that can help inform pre-hospital planning in the Republic of Ireland. In view of Ireland’s heterogeneous settlement pattern, we analyse the association between varying degrees of rurality, OHCA incidence and the availability of the Chain of Survival. In addition to population density, settlement size, proximity to urban centres and land use is taken into account which results in six classes: city; town; accessible village; remote village; accessible rural; remote rural. Results show that, when adjusted for age and sex, the incidence of adult OHCA decreases with increasing rurality. Furthermore, while distance to the nearest ambulance station and call-response interval is greater with increasing rurality, the lowest levels of bystander cardiopulmonary resuscitation occur in the most urban class. To the best of our knowledge, this is one of the very first whole-country geographic descriptions of OHCA to be performed internationally. It is also the first OHCA study to use a multi-class urban-rural classification that considers rurality as more than a function of population density.