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 new preliminary research presented at the American Heart Association’s Scientific Sessions 2026. The study, based on 20 years of national U.S. death certificate data from the CDC’s WONDER database, highlights stark disparities in emergency cardiac care access.
The findings matter because heart attacks are common and often fatal outside hospitals. In the U.S., someone experiences a heart attack every 40 seconds, and about 50% of fatal heart attacks occur outside of the hospital, according to the American Heart Association’s 2026 Heart Disease and Stroke Statistics. The new study analyzed place of death for more than 2.5 million adults aged 20 and older who died from heart attack between 2003 and 2023.
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 people in large metropolitan areas. Black adults who had heart attacks were about 16% more likely to die prior to hospital arrival 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, particularly those between ages 20 and 44, disproportionately died from heart attacks outside of the hospital, potentially because of delayed recognition of heart attacks in this age group. “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,” said study author Darshan Shivanne Gowda, M.B.B.S, a medical student at Hassan Institute of Medical Sciences in Karnataka, India.
Gowda emphasized that getting emergency care as soon as possible can make a major difference. “The message for patients and families is simple: know the warning signs of a heart attack and do not wait to seek help,” he said. “Call 9-1-1 immediately when symptoms occur.”
The American Heart Association has identified the rural health crisis as one of the top three barriers to achieving health care access. The association has funded a multi-pronged approach to improving health in rural America, including delivering resources to strengthen rural and tribal communities, funding scientific research, and creating a Rural Health Care Outcomes Accelerator. More information is available through the association’s Rural Health | American Heart Association resources and its Warning Signs of a Heart Attack page.
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, noted that rural communities may face longer distances to hospitals, fewer emergency and specialty cardiovascular services, and transportation challenges. “Where someone lives should not determine whether they survive a cardiovascular emergency,” said Contreras, who was not involved in the research.
The study is observational and cannot prove causation, and place of death is 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, and the abstract is available online. Additional details can be found in the release link and the Spanish news release. For more information, visit heart.org or stroke.org.
