BACKGROUND: Little is known about healthcare-seeking behaviour and barriers to care for cardiovascular disease (CVD) in sub-Saharan Africa. METHODS: Emergency department patients in Tanzania with acute CVD were prospectively enrolled. Questionnaires were administered at enrollment and 30 d later. RESULTS: Of 241 patients, 186 (77.2%) had visited another facility for the same illness episode (median symptom duration prior to presentation was 7 d) and 82 (34.0%) reported that they were initially unaware of the potential seriousness of their symptoms. Of the 208 (86.3%) patients completing follow-up, 16 (7.7%) had died, 38 (18.3%) had visited another facility for persistent symptoms, 99 (47.6%) felt they understood their diagnosis, 87 (41.8%) felt they understood their treatment and 11 (7.8%) could identify any of their medications. Predictors of 30 d survival with symptom improvement included medication compliance (p<0.001), understanding the diagnosis (p=0.007), understanding the treatment (p<0.001) and greater CVD knowledge (p=0.008). CONCLUSIONS: Patients with CVD in Tanzania usually visit multiple facilities for the same illness episode, typically after prolonged delays. Only a minority understand their diagnosis and treatment, and such understanding is correlated with survival with symptom improvement. Patient-centred interventions are needed to improve the quality of cardiovascular care in Tanzania.