A study of U.S. death-certificate data covering more than 2.5 million adults who died of heart attacks from 2003 to 2023 found rural residents were 2.9 times more likely than urban residents to die before reaching a hospital.

The gap also appeared in where people died: compared with metropolitan residents, rural residents were 89% more likely to die at home and 58% more likely to die in outpatient or emergency-care settings.

The analysis found racial differences as well: Black adults were about 16% more likely than white adults to die before reaching a hospital and 25% more likely to die in outpatient facilities, while Hispanic adults were more likely than non-Hispanic adults to die in hospital.

Researchers and commentators said longer distances, fewer emergency and specialist services, transportation barriers and delays in recognizing symptoms could contribute to these disparities, but the study did not establish their causes or directly measure those factors.

Researcher Darshan Shivanne Gowda urged people of every age who may be having a heart attack to recognize warning signs and call 9-1-1 promptly rather than drive themselves, while emphasizing reliable emergency and specialized cardiovascular care in rural communities.

The findings are scheduled for presentation at the American Heart Association’s Scientific Sessions in Chicago, Nov. 6–9, 2026, and remain preliminary until published in a peer-reviewed journal.

Because the research is observational and based on a conference abstract, it cannot prove causation; moreover, place of death only indirectly reflects access to emergency care.