ERWomen are less likely than men to survive a heart attack because of delays in getting to treatment, according to an Italian study.

The reasons, researchers found, is because women wait much longer before calling emergency medical services, and even once they do, women face much longer delays in getting to a hospital equipped to care for heart attack patients.

The study, to be presented March 14 at the American College of Cardiology’s Scientific Session, showed that women were nearly twice as likely as men to die in the hospital — 12 percent of women died compared with 6 percent of men.

Researchers examined medical records from nearly 7,500 European patients enrolled from 2010 to 2014 in an international registry. They found women waited an average of one hour to call EMS compared with 45 minutes for men. Even after calling for help, seven in 10 women had to wait at least an hour to get to a hospital that could treat them, while only three in 10 men experienced the same delay.

Once patients were admitted, however, there were no significant differences between men and women in time to treatment with a medication to break up blood clots or with balloon angioplasty to open clogged arteries. Men and women who got to the hospital within an hour and received treatment quickly had similar rates of survival.

Cardiovascular diseases cause one in three women’s deaths each year, killing approximately one woman every minute, according to the American Heart Association.

Raffaele Bugiardini, M.D., professor of cardiology at the University of Bologna led the study and said it is time to look beyond what happens in the hospital.

“In the last decade, hospitals in the U.S. and other countries have spent a lot of money improving in-hospital time to treatment for heart attack, but nobody considered what happens before they actually get to the hospital,” Bugiardini said in a statement.

One challenge, he noted, is that women may not have chest pain during a heart attack. Instead, they may have shortness of breath, nausea, vomiting or pain in the back, neck or jaw. The symptoms may develop slowly and come and go, leading some women and even doctors to assume the symptoms are caused by mundane health conditions such as indigestion.

“A lot of the initial descriptions [about symptoms] were written about men at a time when we mistakenly believed this was predominantly a disease of men,” said Richard Chazal, M.D., vice president of the American College of Cardiology. “It is important for physicians and patients to recognize that the symptoms are not always the classic ‘elephant sitting on my chest’ that we hear about.”

Researchers said future studies are needed to identify the factors associated with prehospital delays among women having a heart attack so that initiatives can be developed to improve timely care and survival.