People living in rural areas who experience a heart attack are nearly three times more likely to die before reaching a hospital compared to residents of large metropolitan areas, according to preliminary research presented at the American Heart Association's Scientific Sessions 2026. The findings, based on 20 years of national death certificate data, highlight stark geographic and demographic disparities in access to time-sensitive emergency care.
The study analyzed more than 2.5 million adults aged 20 and older who died from a heart attack between 2003 and 2023 using the CDC WONDER database. Researchers found that rural residents were not only nearly three times more likely to die before hospital arrival, but also about 89% more likely to die at home and 58% more likely to die in outpatient or emergency care settings than their urban counterparts.
"Getting emergency care as soon as possible can make a major difference in a life-threatening situation," said study author Darshan Shivanne Gowda, M.B.B.S., a medical student at Hassan Institute of Medical Sciences in Karnataka, India. "We found that people who live in rural areas and certain other populations were more likely to die before receiving urgent care for a heart attack that would improve their chances of survival."
The study also uncovered significant racial and age disparities. Black adults who had heart attacks were about 16% more likely to die before reaching the hospital and 25% more likely to die at outpatient facilities compared to white adults, potentially reflecting inequities in pre-hospital care. Young adults aged 20 to 44 disproportionately died from heart attacks outside the hospital, possibly due to delayed recognition of symptoms. Men were 20% to 40% more likely to die before hospital arrival than women.
"The message for patients and families is simple: know the warning signs of a heart attack and do not wait to seek help," Gowda said. "Call 9-1-1 immediately when symptoms occur." The American Heart Association provides Warning Signs of a Heart Attack to help the public recognize symptoms.
The findings reinforce the American Heart Association's identification of the rural health crisis as a top barrier to health care access. The organization has funded a multi-pronged approach to improve rural health, including resources for self-measured blood pressure monitors, CPR education, and a Rural Health Care Outcomes Accelerator. More information is available through the association's Rural Health | American Heart Association resources.
"Heart attack is a time-sensitive emergency," said Johanna Paola Contreras, M.D., FAHA, a member of the American Heart Association's International Committee and founder of its National Hispanic Latino Cardiovascular Collaborative. "Rural communities may face longer distances to hospitals, fewer emergency and specialty cardiovascular services, and challenges with transportation and access to timely care." She emphasized that where someone lives should not determine whether they survive a cardiovascular emergency.
The study's limitations include its retrospective observational design, which cannot prove causation, and the use of place of death as an indirect measure of emergency care access. The findings are considered preliminary until published in a peer-reviewed journal. The abstract is available in the abstract and the 2026 Online Program Planner. A Spanish news release is also available.
