BACKGROUND: Particulate exposure from air pollution increases the risk of ischemic heart disease (IHD) mortality. Although coal miners are highly exposed to coal dust particulate, studies of IHD mortality risk among coal miners have had inconsistent results. Previous studies may have been biased by the healthy worker effect. METHODS: We examined the dose-response relationship between cumulative coal dust exposure, coal rank, and IHD mortality among a cohort of underground coal miners who participated in the National Study of Coal Workers' Pneumoconiosis. RESULTS: After adjusting for age, smoking, and body mass index, risk of IHD mortality increased at higher levels of coal dust exposure. Mortality risk was also associated with coal rank region. CONCLUSION: There was an increased risk of mortality from IHD associated with cumulative exposure to coal dust, and with coal rank. The effect of coal rank may be due differences in the composition of coal mine dust particulate. The association of risk of IHD mortality with cumulative particulate exposure is consistent with air pollution studies.