Pulmonary hypertension (PH) is a progressive disease consisting of a group of disorders, all consisting of a resting elevated pulmonary artery pressure greater than 25 mm Hg.1 It is classified into 5 groups: Group 1 due to primary arterial hypertension , group 2 due to left heart disease (the most common and deadly cause of PH2), group 3 due to lung diseases such as interstitial or obstructive lung disease or hypoxia, group 4 due to chronic pulmonary arterial obstruction such as thromboembolism, and group 5 due to multifactorial causes.3 Poor prognosis, persistent older age of the population resulting in left heart4 and lung disease,5 as well as overall improved diagnostics for PH WHO Groups 1-5,6 leading to earlier disease detection, have likely contributed to continued high rates of PH hospitalizations and mortality within the United States. Therefore, despite initially stabilizing between 1980 and 2001,7 PH age-adjusted mortality rate has continued to increase through 2019.8,9

Additionally, high rates of misdiagnosis, misclassification, and suboptimal treatment attribute greatly to the observed increased mortality rates.10 Tertiary PH centers are characterized as having PH-trained physicians, PH-trained nursing teams, and the centers participate in random-controlled PH trials.10 As PH care is well-recognized to be a complex and multidisciplinary, patient referral to tertiary PH centers is required early in the diagnostic process, even prior to a complete prereferral diagnosis.10 Although race and sex disparities have been reported alongside previous PH mortality trend data, rural-urban data has yet to be updated in the literature past 2011.11 Given the importance of early access to tertiary centers for PH disease progression, this study seeks to 1) identify rural-urban trends in PH mortality between 2004 and 2019 and 2) highlight the lack of access of tertiary PH care centers to rural residents within the United States.