Among 79,258 heart failure hospitalizations in adults aged 18–45 drawn from the National Inpatient Sample (2016–2022), rural patients faced a 28% higher adjusted risk of in-hospital death compared to urban peers (1.6% vs. 1.2%; aRR = 1.28, 95% CI 1.05–1.56). Rural patients also underwent advanced cardiac procedures at higher rates (aIRR = 1.19) and experienced 10% longer hospital stays. Critically, race and payer type significantly modified the rural-urban mortality association, signaling compounding inequities.
Heart failure in young adults is an underappreciated and rising crisis — distinct from the older-adult phenotype, often tied to structural disease, substance use, obesity, and uncontrolled hypertension. This analysis adds granularity by isolating the rural penalty in a demographic rarely centered in cardiovascular disparity research. The finding that small and medium metropolitan residents fared similarly to urban patients suggests a sharp rural threshold rather than a gradient, pointing to acute access gaps — fewer cardiologists, delayed transfers, limited outpatient follow-up — rather than gradual resource decline.
Important limitations apply: the National Inpatient Sample captures hospitalizations, not incidence or post-discharge outcomes, so mortality is likely undercounted. Observational design prevents causal inference, and residual confounding from socioeconomic variables is probable. As a preprint not yet peer-reviewed, these findings require independent validation before informing policy. Still, the scale of the dataset and consistency of adjusted estimates make this a meaningful, if not paradigm-shifting, contribution to rural cardiovascular equity literature.