Abstract Body (Do not enter title and authors here): Background: Recent studies have demonstrated increased mortality rates in Takotsubo syndrome (TTS) based on the social determinants of health including racial disparities and median incomes. An often-overlooked factor is the rurality or urbanization of one’s community, especially since rural patients have significantly higher cardiovascular mortality rates. To date, there are limited studies on TTS patient outcomes in rural versus urban hospital settings.

Research Question: What are the mortality trends in rural versus urban TTS patients, and which features contribute the most to mortality?

Aims: To identify differences in mortality rates in rural versus urban TTS patients and identify features contributing the most to mortality

Methods: We conducted a retrospective study using the National Inpatient Sample database from 2006 to 2020 to select patients ≥18 years old with a primary diagnosis of TTS. We analyzed mortality rates annually and in five-year intervals, and patients were grouped by rural versus urban hospital settings. Clustering analysis was performed on available demographic and socioeconomic variables, which grouped patients based on how similar they are relative to other groups. Feature analysis was then utilized to identify which features contributed most to the clustering results.

Results: Of 77,790 TTS patients, the mean age was 67.1±14.0 years old, and 65,824 (84.6%) were female. Of TTS admission, 5062 (6.5%) were at rural hospitals and 72,728 (93.5%) were at urban centers. The overall mortality rate was 5.7% (4417) from 2006 to 2020, with 4.1% (206) in rural hospitals and 5.8% (4211) in urban hospitals (p-value < 0.001). Subgroup analysis showed mortality rates of 3.0% (25) versus 3.8% (340) (p-value = 0.26) in 2006 to 2010, 4.0% (73) versus 5.3% (1414) (p-value = 0.02) in 2011 to 2015, and 4.5% (108) versus 6.7% (2457) (p-value <0.001) in 2016 to 2020, in rural and urban hospitals, respectively. Feature analysis showed that age, hospital length of stay, and hospital location were the most important features for mortality prediction.

Conclusions: Mortality rates for TTS were higher in urban hospitals compared to rural hospitals, with age, length of stay, and hospital location contributing most to mortality prediction. Increased urban mortality rates may be attributable to transfers of critically ill patients from rural to urban centers and increased disease complexity patients.