Your biggest heart disease questions answered

Is saturated fat still bad? Do you really need to take a statin? What heart tests do you really need?

Published: June 2014

You might think that by now most experts agree on the best ways to prevent, diagnose, and treat heart disease. But developments in the last six months seem to have upended several long-standing assumptions about the disease. And that could mean major changes in the food you eat, the tests you take, and the drugs you need. Most notably:

  • A widely reported study in the Annals of Internal Medicine suggests that saturated fat, long thought to be a major contributor to heart disease by raising LDL (bad) cholesterol, isn’t a dietary demon after all. It has led to headlines such as “Butter Is Back” in The New York Times and gleeful news articles urging people to eat more bacon.
  •  Aggressive new guidelines from the American Heart Association and the American College of Cardiology mean that 13 million more Americans—including almost all men ages 60 to 75 and more than half of women in that age range—should now take a cholesterol-lowering drug, such as atorvastatin (Lipitor and generic) or rosuvastatin (Crestor).
  • A number of leading medical groups have questioned the usefulness of several heart-disease screening tests, including EKGs and exercise stress tests, long part of an annual checkup for millions of Americans, as well as newer and often heavily advertised tests, such as CT scans of the heart.

To make sense of it all, we reviewed the research and talked with Consumer Reports medical and nutrition advisers and other experts for their take. Spoiler alert: We agree with some of the new heart-disease recommendations but have doubts about others.

Is saturated fat still bad?

The study got a lot of us hoping we could chow down on buttery croissants and fried chicken without any risk to our hearts. British researchers looked at 72 previous studies on the role of fat in heart disease and concluded that the evidence didn’t support the advice to cut back on saturated fat, which comes primarily from animal sources, and to eat more unsaturated fat, which comes mainly from vegetables, nuts, and fish.

Well, not so fast. That report got a lot of attention, but less noticed was the authors’ correction a week later. Turns out that when it came to unsaturated fats—the kind in olive oil and fish—they had goofed. Their correction shows that consuming that kind of fat does help protect against heart disease.

That was a relief to many experts. The original study “threw the olive oil out with the bathwater,” Walter Willett, M.D., chairman of the department of nutrition at the Harvard School of Public Health, said. The correction clarified the benefits of unsaturated fats.

But the study has other shortcomings that continue to muddy the message about dietary fat. For example, our experts say that it left out research showing that the benefits of cutting back on saturated fat depend on what you replace it with. “If you stop eating butter or cheese but start eating a lot of sugar or processed foods, you’re unlikely to do your heart or your health in general much good,” said Maxine Siegel, R.D., who heads Consumer Reports research on food and nutrition.

Willett agrees, and points out that considerable research shows that if saturated fat is replaced with unsaturated fats, the risk of heart disease does go down. That’s what two major analyses found, one in 2009 and another in 2012. And a 2013 study in the New England Journal of Medicine found that people at high risk for heart disease lowered their risk for heart attack or stroke by about 30 percent if they followed a Mediterranean-style diet, which is low in saturated fat and high in nuts and extra-virgin olive oil, both of which are good sources of unsaturated fat.

CR’s take: It still pays to watch your intake of saturated fat, Siegel says. Aim for no more than 7 to 10 percent of total calories from the stuff (about 140 to 200 calories if you consume 2,000 calories per day). But equally important is to replace saturated fat with heart-healthy alternatives, such as unsaturated fats, fruit, vegetables, and whole grains—not refined carbs such as those in white bread, sugar, and many snacks. Read more about good fats and bad fats and butter substitutes.  

Do I really need a statin?

Cholesterol-lowering statins are already among the most commonly prescribed medi­cations in the U.S., taken by 20 percent of Americans 45 and older. Under the new guidelines, half of all adults—and nine out of 10 men ages 60 to 75— should now be on the drugs, according to a March analysis in the New England Journal of Medicine.

That jump stems from a new way of determining who needs a cholesterol-lowering drug. The decision is no longer driven mainly by cholesterol levels but by the overall risk of developing cardiovascular disease, also based on such factors as age, blood pressure, and whether a person smokes or has dia­be­tes. Those factors can be entered into a calculator, and if your 10-year heart attack or stroke risk is 7.5 percent or higher, the new guidelines say you need a statin.

Our experts say that you should consider more than just your cholesterol when deciding whether you need a statin. But they worry that the 7.5 percent threshhold for starting drugs is too low. “People often underestimate the ability of lifestyle changes to reduce their risk of heart attack or stroke, and overestimate the benefits of statins,” Marvin M. Lipman, M.D., Consumer Reports’ chief medical adviser, said.

CR’s take: Don’t rush to take a statin, especially if your 10-year cardio­vas­cu­lar risk is less than 10 percent. “It often pays to give lifestyle changes—losing excess weight, exercising more, and stopping smoking—a chance for at least six months before trying drugs,” Lipman said. That can lower your LDL cholesterol and raise your HDL (good) cho­lesterol, lower your blood pressure, and help you control your blood sugar and weight—and possibly eliminate the need for a statin. Read more about the best drugs for treating high cholesterol.

Why don’t I need an EKG?

The temptation to use an imaging test to find heart disease early is strong. That’s why so many physicians make electrocardiograms and exercise stress tests a routine part of annual checkups. It has also led some doctors to recommend newer, more sophis­ticated tests such as CT angiography and coronary calcium scoring. But in the last year, several medical groups representing the very doctors who have traditionally ordered the tests have cautioned people that they can be overused.

EKGs and exercise stress tests.

An EKG is a quick, inexpensive way to get information about how fast and regularly your heart is beating. An exercise stress test is an EKG done while you walk or jog on a treadmill, and it provides information about how your heart responds to activity. Both tests are common: A Consumer Reports survey of almost 1,200 people ages 40 to 60 with no history of heart disease or heart-disease symptoms found that 39 percent had undergone an EKG and 12 per­cent an exercise stress test. But the American College of Physicians, the American Academy of Family Physicians, and the American College of Cardiology now say that neither test should be part of a routine checkup.

CR’s take: “We agree,” Lipman said. Why? The tests are less accurate in those people and can lead to expensive, unnecessary follow-up tests that expose them to potentially cancer-causing radi­ation. They’re best reserved for peo­ple with heart-disease symptoms, such as chest pain, shortness of breath, or palpitations. They may also be useful for people with diabetes or multiple coronary risk factors who are starting to exercise.

CT angiography and coronary calcium scoring

Those high-tech tests use CT scans to take images of your coronary arteries. With coronary calcium scoring, doctors assign a number to the amount of calcium deposits. With CT angi­ography, doctors inject a contrast dye into your veins and then take multiple X-ray images to identify arteries narrowed by plaque. Both are now sometimes pitched directly to consumers. But the Society of Cardiovascular Computed Tomography, the medical group that represents doctors who use CT scans to assess the heart, now says that neither should be used to screen for heart disease in low-risk people.

CR’s take: “We agree with this, too,” Lipman said. Both tests expose you to radiation and can have misleading results, said Randall C. Thompson, M.D., professor of medicine at the University of Missouri School of Medicine in Kansas City and a member of the SCCT. Neither has been proved to help most low-risk people. Possible exceptions are those without symptoms but with a family history of heart disease, who might benefit from calcium scoring. People with symptoms might consider CT angiography.

Read more about the heart disease tests you really need.

3 tips for interpreting medical news

“Making sense of health news is complicated, but it’s important, especially when it comes to heart disease,” Lipman said. To help you interpret the inevitable next round of research and advice, he offers the following tips.

1. One study rarely changes decades of advice. Even major analyses that seem to comprehensively round up previous research rarely tell the whole story.

2. Newer doesn’t mean better. That’s true of drugs and treatments, tests, and research.

3. Less is often more. Simple steps, such as making lifestyle changes before resorting to drugs and avoiding tests you don’t need, are often the best medicine.



Editor's Note:

This article appeared in the July 2014 issue of Consumer Reports on Health.

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