Pooling 13 prospective cohorts and 54,034 patients with established cardiovascular disease, higher Mediterranean diet adherence tracked with lower all-cause mortality (RR 0.74, 95% CI 0.65-0.84), cardiovascular mortality (RR 0.84, 0.75-0.94), and recurrent cardiovascular events (RR 0.60, 0.39-0.92). Follow-up ran 2 to 10 years across more than 13,000 events. Sensitivity analyses held, though heterogeneity was moderate to high and publication bias appeared for recurrent events, with the estimate surviving trim-and-fill correction.
The mortality signal is clinically meaningful, but the design limits what it proves. These are observational cohorts, so healthier, more engaged patients may both eat better and take medications more reliably, and diet is usually self-reported. Reverse causation also matters: patients sicker at baseline may eat less well. The recurrent-events estimate has an especially wide interval and the publication-bias flag, so treat it as hypothesis-generating. The only randomized evidence for secondary prevention remains CORDIOPREV (Mediterranean versus low-fat diet in coronary patients) and the older Lyon Diet Heart Study, both favorable and consistent in direction with this pooled result. Adherence scores also differ across cohorts, which likely explains much of the heterogeneity. Editorially, this is confirmatory rather than paradigm-shifting, but it usefully fills an evidence gap. For adults after a heart attack or stroke, the practical message is that dietary pattern deserves attention alongside statins, blood-pressure control, and cardiac rehabilitation, not as a substitute for them.