People living in rural areas who experienced a heart attack were nearly three times more likely to die before reaching hospital care, compared with those living in large metropolitan areas, according to new, independent, preliminary research presented at the American Heart Association’s Scientific Sessions 2026, held Nov. 6–9 in Chicago.
In the U.S., someone experiences a heart attack every 40 seconds, according to the American Heart Association’s 2026 Heart Disease and Stroke Statistics, with about 50% of fatal heart attacks occurring outside of the hospital.
Previously, there were limited data on exactly which populations and demographics were at greater risk of death before reaching hospital care. This study explored participants’ location at the time of heart attack and death, distance to the nearest hospital and whether deaths differed according to their age, sex, race, Hispanic ethnicity and urban or rural residency.
“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.”
Key findings
- Rural residents were nearly three times more likely to die before hospital arrival, as well as about 89% more likely to die at home and 58% more likely to die in outpatient or emergency care settings than people who live in large metropolitan areas.
- Black adults who experienced heart attacks were about 16% more likely to die prior to arrival at the hospital and 25% more likely to die at outpatient facilities compared with white adults, which may reflect racial inequities in prehospital care.
- In contrast, Hispanic adults who died from heart attacks were more likely to die in the hospital than non-Hispanic adults.
- Overall, men were 20%–40% more likely to die from a heart attack before hospital arrival than women.
- Adults older than 65 were up to six times more likely to die in a long-term care facility after a heart attack.
- Young adults, particularly those between ages 20 and 44, disproportionately died from heart attacks that occurred outside of the hospital, potentially because of delayed recognition of heart attacks among this age group.
“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 911 immediately when symptoms occur. At the same time, our findings show that communities need reliable emergency medical services and timely access to specialized heart attack care, regardless of where people live.”
“We were also struck by the higher likelihood of out-of-hospital death among younger adults,” he said. “Heart attacks are often perceived as primarily affecting older adults, so the finding that younger adults had the highest relative odds of death by the time they reached the hospital underscores the importance of recognizing heart attack symptoms across all age groups.”
The American Heart Association has identified the rural health crisis as one of the top three barriers to achieving health care access and improving care for all people. Recognizing the gaps in health care for rural Americans, the association has endorsed a multipronged approach to improving health in rural America.
“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 Community Engagement Committee and founder of the association’s 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.”
“Although this study cannot tell us which of these factors explains the difference, the findings reinforce the importance of strengthening emergency medical services, prevention, early recognition and access to specialized cardiovascular care in rural communities. Our goal should be simple: where someone lives should not determine whether they survive a cardiovascular emergency.”
Contreras, who was not involved in this research, is an associate professor of medicine (cardiology) at Icahn School of Medicine at Mount Sinai; director of Heart Failure and Cardiomyopathy Clinical and Research Network at Mount Sinai Fuster Heart Hospital and medical director of the Hispanic Heart Center at Mount Sinai Health System in New York City. She noted that the responsibility for improving outcomes among rural patients belongs to families, health care professionals and policymakers.
“Everyone must know the warning signs of a heart attack and act quickly,” she said. “If symptoms suggest a heart attack, call 911 rather than trying to drive yourself to the hospital. And importantly, being young does not exclude the possibility of a heart attack.
“The disproportionate number of out-of-hospital deaths among younger adults in this study reminds us that serious cardiovascular symptoms need to be recognized at every age. Communities and health systems must also provide reliable emergency medical services and pathways that allow people to reach appropriate cardiovascular care quickly, particularly when they live far from a hospital.”
Study details, background, design and limitations
- Researchers reviewed death certificate data from the CDC WONDER database for deaths occurring in the U.S. between 2003 and 2023.
- The study analyzed the place of the heart attack and death for more than 2.5 million adults (ages 20 or older) who died from a heart attack.
- Rural areas were defined as counties outside metropolitan areas and classified as either micropolitan or noncore areas. Micropolitan areas center around small urban clusters of 10,000–49,999 residents, whereas noncore areas lack a substantial urban center and represent more geographically isolated rural communities, Gowda explained.
- Place of death was categorized as upon hospital arrival, outpatient or emergency setting, home, hospice or nursing home/long-term care facilities.
- The retrospective, observational study cannot prove direct causation among sociodemographic factors, location and death.
- Place of death is an indirect measure of emergency care access because it does not directly account for when heart attack symptoms began, emergency response and transportation times, distance to hospitals, proximity to heart attack specialty care or other delays in seeking or accessing care.
Key medical concepts
Clinical categories
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Rural residents face nearly three times higher risk of heart attack death before reaching a hospital (2026, November 2)
retrieved 2 November 2026
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