People living in rural areas who experience a heart attack are nearly three times more likely to die before reaching hospital care compared to those in large metropolitan areas, according to preliminary research presented at the American Heart Association’s Scientific Sessions 2026. The study, which analyzed 20 years of national death certificate data from the CDC’s WONDER database, sheds light on stark geographic and demographic disparities in heart attack survival.
The findings are particularly significant given that someone in the U.S. experiences a heart attack every 40 seconds, and about half of fatal heart attacks occur outside of a hospital, according to the Association’s 2026 Heart Disease and Stroke Statistics. The study is the first to comprehensively examine which populations are at greater risk of pre-hospital death.
Researchers reviewed data on more than 2.5 million adults who died from heart attacks between 2003 and 2023. They 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. Black adults were about 16% more likely to die before reaching the hospital and 25% more likely to die at outpatient facilities compared to white adults, which researchers suggest may reflect racial inequities in pre-hospital care. Men were 20% to 40% more likely to die before hospital arrival than women. Young adults aged 20 to 44 also disproportionately died from heart attacks outside of the hospital, possibly due to delayed recognition of symptoms.
“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 American Heart Association has identified the rural health crisis as one of the top three barriers to achieving equitable health care access. The organization has funded a multi-pronged approach to improving rural health, including delivering resources such as self-measured blood pressure monitors and CPR education, funding scientific research, and creating a Rural Health Care Outcomes Accelerator. More information about the Association’s rural health initiatives is available at Rural Health | American Heart Association.
“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. Our goal should be simple: 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 research will be presented at Scientific Sessions 2026, to be held Nov. 6-9 in Chicago. The abstract and 2026 Online Program Planner are available online. For warning signs, see the Association’s Warning Signs of a Heart Attack.
Gowda emphasized the importance of public awareness: “Know the warning signs of a heart attack and do not wait to seek help. Call 9-1-1 immediately when symptoms occur.”
