Link between Mediterranean diet and risk factors for acute coronary syndrome


  • Radmila Velicki Faculty of Medicine, University of Novi Sad, Novi Sad, (Serbia), Institute of Public Health of Vojvodina, Novi Sad, (Serbia)
  • Milovan Petrovic Faculty of Medicine, University of Novi Sad, Novi Sad, (Serbia), Institute of cardiovascular diseases Vojvodina, Sremska Kamenica, (Serbia)
  • Sanja Bijelovic Faculty of Medicine, University of Novi Sad, Novi Sad, (Serbia), Institute of Public Health of Vojvodina, Novi Sad, (Serbia)
  • Jelena Bjelanovic Faculty of Medicine, University of Novi Sad, Novi Sad, (Serbia), Institute of Public Health of Vojvodina, Novi Sad, (Serbia)
  • Natasa Dragic Faculty of Medicine, University of Novi Sad, Novi Sad, (Serbia), Institute of Public Health of Vojvodina, Novi Sad, (Serbia)
  • Milka Popovic Faculty of Medicine, University of Novi Sad, Novi Sad, (Serbia), Institute of Public Health of Vojvodina, Novi Sad, (Serbia)
  • Lazar Velicki Faculty of Medicine, University of Novi Sad, Novi Sad, (Serbia), Institute of cardiovascular diseases Vojvodina, Sremska Kamenica, (Serbia)


Cardiovascular diseases, Improper nutrition, Mediterranean diet, Acute coronary syndrome, MedDiet Score, Coronary artery disease, Coronary heart disease


Background and aim: A few studies have investigated the potential of the Mediterranean diet (MD) in secondary prevention of cardiovascular diseases (CVDs) and its possibility in alleviating the course and consequences of the diseases in a population following MD principles. The primary objectives of this study are to assess the level of adherence to the MD in patients with acute coronary syndrome (ACS) and in individuals at risk of developing CVDs, using a validated MedDiet score. Additionally, we aim to investigate whether the MD can play a protective role in reducing the occurrence and severity of ACS.

Methods: The study examined 294 subjects, evenly split by gender, between the ages of 30 and 82, using an analytical cross-sectional method. Among all participants in the study the following examinations were conducted: anthropometric measurements, arterial blood pressure measurements, appropriate biochemical analysis, ECG and surveys using a specially prepared questionnaire, which included MedDiet score – validated score system for assessing the degree of compliance with MD pattern among subjects.

Results: The study found that the mean MedDiet score of participants without ACS was significantly higher than that of participants with ACS (27.48 and 20.53 respectively, p=0.029). The MedDiet score was determined as an excellent marker for ACS with a cut-off value of 22.5, with a score of 22.5 or lower considered as an unfavorable result, and a score above 22.5 considered as a favorable result. The MedDiet score was found to have a negative correlation with systolic blood pressure, blood glucose values, serum triglyceride values and weak positive correlation with serum HDL values, atherosclerosis index and cardiac necrosis biomarker.

Conclusions: Mediterranean diet has a protective effect on the incidence and severity of acute coronary syndrome in patients who are already ill and in those at a higher risk of developing cardiovascular disease.


Joseph P, Leong D, McKee M, et al. Reducing the Global Burden of Cardiovascular Disease, Part 1: The Epidemiology and Risk Factors. Circ Res. 2017; 121(6): 677-694. doi:10.1161/CIRCRESAHA.117.308903

Roth GA, Mensah GA, Johnson CO, et. al. Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update from the GBD 2019 Study. J Am Coll Cardiol. 2020;76(25): 2982-3021. doi:10.1016/j.jacc.2020.11.010

Papanikolaou Y, Fulgoni VL 3rd. Dairy Food Consumption Is Associated with Reduced Risk of Heart Disease Mortality, but Not All-Cause and Cancer Mortality in US Adults. Nutrients. 2023; 15(2): 394. doi:10.3390/nu15020394

Badimon L, Chagas P, Chiva-Blanch G. Diet and Cardiovascular Disease: Effects of Foods and Nutrients in Classical and Emerging Cardiovascular Risk Factors. Curr Med Chem. 2019; 26(19): 3639-3651. doi:10.2174/0929867324666170428103206

Chareonrungrueangchai K, Wongkawinwoot K, Anothaisintawee T, et al. Dietary Factors and Risks of Cardiovascular Diseases: An Umbrella Review. Nutrients. 2020; 12(4):1088. doi:10.3390/nu12041088

Migliaccio S, Brasacchio C, Pivari F, et al. Obesity Programs of nutrition, Education, Research and Assessment (OPERA) Group. What is the best diet for cardiovascular wellness? A comparison of different nutritional models. Int J Obes Suppl. 2020; 10(1): 50-61. doi:10.1038/s41367-020-0018-0

Jayedi A, Soltani S, Abdolshahi A, et al. Healthy and unhealthy dietary patterns and the risk of chronic disease: an umbrella review of meta-analyses of prospective cohort studies. Br J Nutr. 2020; 124(11): 1133-1144. doi:10.1017/S0007114520002330

Dominguez LJ, Di Bella G, Veronese N, et al. Impact of Mediterranean Diet on Chronic Non-Communicable Diseases and Longevity. Nutrients. 2021; 13(6): 2028. doi:10.3390/nu13062028

Rees K, Takeda A, Martin N, et al. Mediterranean-style diet for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2019; 3(3): CD009825. doi:10.1002/14651858.CD009825.pub3

Salas-Salvadó J, Becerra-Tomás N, García-Gavilán JF, et al. Mediterranean Diet and Cardiovascular Disease Prevention: What Do We Know? Prog Cardiovasc Dis. 2018; 61(1): 62-67. doi:10.1016/j.pcad.2018.04.006

Davis C, Bryan J, Hodgson J, et al. Definition of the Mediterranean Diet; a Literature Review. Nutrients. 2015; 7(11): 9139-53. doi:10.3390/nu7115459

Menotti A, Puddu PE. How the Seven Countries Study contributed to the definition and development of the Mediterranean diet concept: a 50-year journey. Nutr Metab Cardiovasc Dis. 2015; 25(3): 245-252. doi:10.1016/j.numecd.2014.12.001

Dernini S, Berry EM, Serra-Majem L, et al. Med Diet 4.0: the Mediterranean diet with four sustainable benefits. Public Health Nutr. 2017; 20(7): 1322-1330. doi:10.1017/S1368980016003177

Sofi F, Cesari F, Abbate R, et al. Adherence to Mediterranean diet and health status: meta-analysis. BMJ. 2008; 337: a1344. doi:10.1136/bmj.a1344

Jimenez-Torres J, Alcalá-Diaz JF, Torres-Peña JD, et al. Mediterranean Diet Reduces Atherosclerosis Progression in Coronary Heart Disease: An Analysis of the CORDIOPREV Randomized Controlled Trial. Stroke. 2021; 52(11): 3440-3449. doi:10.1161/STROKEAHA.120.033214

Ros E, Martínez-González MA, Estruch R, et al. Mediterranean diet and cardiovascular health: Teachings of the PREDIMED study. Adv Nutr. 2014; 5(3): 330S-6S. doi:10.3945/an.113.005389

Martínez-González MA, Salas-Salvadó J, Estruch R, et al. PREDIMED INVESTIGATORS. Benefits of the Mediterranean Diet: Insights From the PREDIMED Study. Prog Cardiovasc Dis. 2015; 58(1): 50-60. doi:10.1016/j.pcad.2015.04.003

de Lorgeril M, Salen P, Martin JL, et al. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999; 99(6): 779-85. doi:10.1161/01.cir.99.6.779

Tang C, Wang X, Qin LQ, et al. Mediterranean Diet and Mortality in People with Cardiovascular Disease: A Meta-Analysis of Prospective Cohort Studies. Nutrients. 2021; 13(8): 2623. doi:10.3390/nu13082623

Panagiotakos DB, Pitsavos C, Stefanadis C. Dietary patterns: a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk. Nutr Metab Cardiovasc Dis. 2006; 16(8): 559-568. doi:10.1016/j.numecd.2005.08.006

Collet JP, Thiele H, Barbato E, et al.. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021; 42(14): 1289-1367 Erratum in: Eur Heart J. 2021; 42(19): 1925. doi:10.1093/eurheartj/ehaa575

Guedeney P, Collet JP. Diagnosis and Management of Acute Coronary Syndrome: What is New and Why? Insight From the 2020 European Society of Cardiology Guidelines. J Clin Med. 2020; 9(11): 3474. doi:10.3390/jcm9113474

Gutterman DD. Silent myocardial ischemia. Circ J. 2009; 73(5): 785-797. doi:10.1253/circj.cj-08-1209

Martin-Moreno JM, Boyle P, Gorgojo L, et al. Development and validation of a food frequency questionnaire in Spain. Int J Epidemiol 1993; 22: 512–519. doi:10.1093/ije/22.3.512

Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019; 140(11): e596-e646. doi:10.1161/CIR.0000000000000678

Liu K, Daviglus ML, Loria CM, et al. Healthy lifestyle through young adulthood and the presence of low cardiovascular disease risk profile in middle age: the Coronary Artery Risk Development in (Young) Adults (CARDIA) study. Circulation. 2012; 125(8): 996-1004. doi:10.1161/CIRCULATIONAHA.111.060681

Eguaras S, Toledo E, Hernández-Hernández A, et al. Better Adherence to the Mediterranean Diet Could Mitigate the Adverse Consequences of Obesity on Cardiovascular Disease: The SUN Prospective Cohort. Nutrients. 2015; 7(11): 9154-9162. doi:10.3390/nu7115457

Sanches Machado d'Almeida K, Ronchi Spillere S, Zuchinali P, et al. Mediterranean Diet and Other Dietary Patterns in Primary Prevention of Heart Failure and Changes in Cardiac Function Markers: A Systematic Review. Nutrients. 2018; 10(1): 58. doi:10.3390/nu10010058

Kouvari M, Tsiampalis T, Chrysohoou C, et al. A Mediterranean diet microsimulation modeling in relation to cardiovascular disease burden: the ATTICA and GREECS epidemiological studies. Eur J Clin Nutr. 2022; 76(3): 434-441. doi:10.1038/s41430-021-00967-6

Buckland G, González CA, Agudo A, et al. Adherence to the Mediterranean diet and risk of coronary heart disease in the Spanish EPIC Cohort Study. Am J Epidemiol. 2009; 170(12): 1518-1529. doi:10.1093/aje/kwp282

Estruch R, Martínez-González MA, Corella D, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med. 2006; 145(1): 1-11. doi:10.7326/0003-4819-145-1-200607040-00004

Doménech M, Roman P, Lapetra J, et al. Mediterranean diet reduces 24-hour ambulatory blood pressure, blood glucose, and lipids: one-year randomized, clinical trial. Hypertension. 2014; 64(1): 69-76. doi:10.1161/HYPERTENSIONAHA.113.03353

Papadaki A, Nolen-Doerr E, Mantzoros CS. The Effect of the Mediterranean Diet on Metabolic Health: A Systematic Review and Meta-Analysis of Controlled Trials in Adults. Nutrients. 2020; 12(11): 3342. doi:10.3390/nu12113342

Panagiotakos DB, Arapi S, Pitsavos C, et al. The relationship between adherence to the Mediterranean diet and the severity and short-term prognosis of acute coronary syndromes (ACS): The Greek Study of ACS (The GREECS). Nutrition. 2006; 22(7-8): 722-730. doi:10.1016/j.nut.2006.04.005

Panagiotakos DB, Pitsavos C, Stefanadis C. GREECS Study Investigators. Short-term prognosis of patients with acute coronary syndromes through the evaluation of physical activity status, the adoption of Mediterranean diet and smoking habits: the Greek Acute Coronary Syndromes (GREECS) study. Eur J Cardiovasc Prev Rehabil. 2006; 13(6): 901-908. doi:10.1097/01.hjr.0000221863.42286.1e






Original articles

How to Cite

Velicki R, Petrovic M, Bijelovic S, Bjelanovic J, Dragic N, Popovic M, et al. Link between Mediterranean diet and risk factors for acute coronary syndrome. Progr Nutr [Internet]. 2023 Sep. 27 [cited 2024 Jul. 15];25(3):e2023053. Available from: