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Lipids and cardiovascular health

Mediterranean diet and prognosis of first-diagnosed Acute Coronary Syndrome patients according to heart failure phenotype: Hellenic Heart Failure Study



Nutrition in secondary prevention of Acute Coronary Syndrome (ACS) is inadequately investigated. We sought to evaluate the role of Mediterranean diet in prognosis of first-diagnosed ACS patients, according to heart failure type.


In 2006–2009, 1000 consecutive patients hospitalized at First Cardiology Clinic of Athens with ACS diagnosis were enrolled in the study. In 2016, 10-year follow-up was performed (75% participation rate). Only n=690 (69%) first-diagnosed ACS patients were included. Adherence to Mediterranean diet was assessed through MedDietScore (range 0–55). Heart failure phenotypes were reduced, mid-range and preserved ejection fraction (that is, HFrEF, HFmrEF and HFpEF, respectively).


Ranking from first to third MedDietScore tertile, fewer 1, 2 and 10-year fatal/non-fatal ACS events were observed. Multivariate logistic regression analysis highlighted a significantly inverse association between MedDietScore and long-term ACS prognosis in 1 year (odds ratio (OR)=0.84, 95% confidence interval (CI) (0.71, 1.00), P=0.05), 2 year (OR=0.91, 95% CI (0.82, 1.00), P=0.04) and 10 year (OR=0.93, 95% CI (0.85, 1.00), P=0.05) follow-up. Further analysis revealed that MedDietScore differentially affected patients’ prognosis according to heart failure phenotype, with short-term impact in HFrEF and HFmrEF patients yet longer positive outcomes in HFpEF and C-reactive protein potentially mediated these relations.


Mediterranean diet seemed to protect against recurrent cardiac episodes in coronary patients with major ACS complications. Results were more encouraging with regard to patients with preserved left ventricle function. Such findings may possess a cost-effective, supplementary-to-medical, treatment approach in this patient category where evidence concerning their management are inconclusive.

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Figure 1


  1. 1

    Murray CJL, Lopez AD,, World Health Organization, World Bank, Harvard School of Public Health The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. World Health Organization: Geneva, Switzerland, 1996.

    Google Scholar 

  2. 2

    Piepoli MF, Corra U, Dendale P, Frederix I, Prescott E, Schmid JP et al. Challenges in secondary prevention after acute myocardial infarction: a call for action. Eur J Prev Cardiol 2016; 6: 299–310.

    Google Scholar 

  3. 3

    Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2016; 18: 891–975.

    Article  Google Scholar 

  4. 4

    Kastorini CM, Milionis HJ, Esposito K, Giugliano D, Goudevenos JA, Panagiotakos DB . The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. J Am Coll Cardiol 2011; 57: 1299–1313.

    CAS  Article  Google Scholar 

  5. 5

    Rees K, Hartley L, Flowers N, Clarke A, Hooper L, Thorogood M et al. 'Mediterranean' dietary pattern for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2013; 12: CD009825.

    Google Scholar 

  6. 6

    de Lorgeril M, Salen P . Mediterranean diet in secondary prevention of CHD. Public Health Nutr 2011; 14: 2333–2337.

    Article  Google Scholar 

  7. 7

    Panagiotakos DB, Notara V, Kouvari M, Pitsavos C . The Mediterranean and other dietary patterns in secondary cardiovascular disease prevention: a review. Curr Vasc Pharmacol 2016; 14: 442–451.

    CAS  Article  Google Scholar 

  8. 8

    de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N . 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: 779–785.

    CAS  Article  Google Scholar 

  9. 9

    Lund LH . Heart failure with 'mid-range' ejection fraction-new opportunities. J Card Fail 2016; 22: 769–771.

    Article  Google Scholar 

  10. 10

    Thygesen KAJ, White HD on Behalf of the Joint ESC/ACCF/AHA/WHF. Task Force for the Redefinition of Myocardial Infarction.. Universal definition of myocardial infarction. Eur Heart J 2007; 28: 2525–2538.

    Article  Google Scholar 

  11. 11

    Braunwald E . Heart Disease, 5th edn. WB Saunders: London, United Kingdom, 1997.

    Google Scholar 

  12. 12

    Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016; 37: 2129–2200.

    Article  Google Scholar 

  13. 13

    Panagiotakos DB, Pitsavos C, Arvaniti F, Stefanadis C . Adherence to the Mediterranean food pattern predicts the prevalence of hypertension, hypercholesterolemia, diabetes and obesity, among healthy adults; the accuracy of the MedDietScore. Prev Med 2007; 44: 335–340.

    Article  Google Scholar 

  14. 14

    Aggelopoulos P, Chrysohoou C, Pitsavos C, Panagiotakos DB, Vaina S, Brili S et al. Sex differences regarding the impact of physical activity on left ventricular systolic function in elderly patients with an acute coronary event. Hellenic J Cardiol 2014; 55: 448–456.

    PubMed  Google Scholar 

  15. 15

    Chrysohoou C, Panagiotakos DB, Aggelopoulos P, Kastorini CM, Kehagia I, Pitsavos C et al. The Mediterranean diet contributes to the preservation of left ventricular systolic function and to the long-term favorable prognosis of patients who have had an acute coronary event. Am J Clin Nutr 2010; 92: 47–54.

    CAS  Article  Google Scholar 

  16. 16

    Kouvari M, Notara V, Panagiotakos DB, Michalopoulou M, Vassileiou N, Papataxiarchis E et al. Exclusive olive oil consumption and 10-year (2004-2014) acute coronary syndrome incidence among cardiac patients: the GREECS observational study. J Hum Nutr Diet 2016; 29: 354–362.

    CAS  Article  Google Scholar 

  17. 17

    Panagiotakos DB, Arapi S, Pitsavos C, Antonoulas A, Mantas Y, Zombolos S 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: 722–730.

    Article  Google Scholar 

  18. 18

    Trichopoulou A, Bamia C, Norat T, Overvad K, Schmidt EB, Tjonneland A et al. Modified Mediterranean diet and survival after myocardial infarction: the EPIC-Elderly study. Eur J Epidemiol 2007; 22: 871–881.

    CAS  Article  Google Scholar 

  19. 19

    Barzi F, Woodward M, Marfisi RM, Tavazzi L, Valagussa F, Marchioli R . Mediterranean diet and all-causes mortality after myocardial infarction: results from the GISSI-Prevenzione trial. Eur J Clin Nutr 2003; 57: 604–611.

    CAS  Article  Google Scholar 

  20. 20

    Singh RB, Dubnov G, Niaz MA, Ghosh S, Singh R, Rastogi SS et al. Effect of an Indo-Mediterranean diet on progression of coronary artery disease in high risk patients (Indo-Mediterranean Diet Heart Study): a randomised single-blind trial. Lancet 2002; 360: 1455–1461.

    Article  Google Scholar 

  21. 21

    Liyanage T, Ninomiya T, Wang A, Neal B, Jun M, Wong MG et al. Effects of the Mediterranean diet on cardiovascular outcomes-a systematic review and meta-analysis. PLoS ONE 2016; 11: e0159252.

    Article  Google Scholar 

  22. 22

    Tektonidis TG, Akesson A, Gigante B, Wolk A, Larsson SC . Adherence to a Mediterranean diet is associated with reduced risk of heart failure in men. Eur J Heart Fail 2016; 18: 253–259.

    Article  Google Scholar 

  23. 23

    Levitan EB, Lewis CE, Tinker LF, Eaton CB, Ahmed A, Manson JE et al. Mediterranean and DASH diet scores and mortality in women with heart failure: the Women's Health Initiative. Circ Heart Fail 2013; 6: 1116–1123.

    CAS  Article  Google Scholar 

  24. 24

    Fox KA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Van de Werf F et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ 2006; 333: 1091.

    Article  Google Scholar 

  25. 25

    Mollema SA, Nucifora G, Bax JJ . Prognostic value of echocardiography after acute myocardial infarction. Heart 2009; 95: 1732–1745.

    CAS  Article  Google Scholar 

  26. 26

    Canto JG, Kiefe CI, Rogers WJ, Peterson ED, Frederick PD, French WJ et al. Number of coronary heart disease risk factors and mortality in patients with first myocardial infarction. JAMA 2011; 306: 2120–2127.

    CAS  Article  Google Scholar 

  27. 27

    Notara V, Panagiotakos DB, Michalopoulou M, Kouvari M, Tsompanaki E, Verdi M et al. Diabetes mellitus, hypertension and hypercholesterolemia in relation to the 10-year ACS prognosis; the GREECS Study. Curr Vasc Pharmacol 2016; 14: 295–301.

    CAS  Article  Google Scholar 

  28. 28

    Tong DC, Wilson AM, Layland J . Novel risk factors for acute coronary syndromes and emerging therapies. Int J Cardiol 2016; 220: 815–824.

    Article  Google Scholar 

  29. 29

    Kaski JC . C-reactive protein improves risk prediction in patients with acute coronary syndrome, or does it? Eur Heart J 2010; 31: 274–277.

    CAS  Article  Google Scholar 

  30. 30

    Siniorakis E, Arvanitakis S, Zarreas E, Saridakis M, Balanis A, Tzevelekos P et al. Mediterranean diet: natural salicylates and other secrets of the pyramid. Int J Cardiol 2013; 166: 538–539.

    Article  Google Scholar 

  31. 31

    Odeberg J, Freitag M, Forssell H, Vaara I, Persson ML, Odeberg H et al. Influence of pre-existing inflammation on the outcome of acute coronary syndrome: a cross-sectional study. BMJ Open 2016; 6: e009968.

    Article  Google Scholar 

  32. 32

    Casas R, Sacanella E, Urpi-Sarda M, Chiva-Blanch G, Ros E, Martinez-Gonzalez MA et al. The effects of the mediterranean diet on biomarkers of vascular wall inflammation and plaque vulnerability in subjects with high risk for cardiovascular disease. A randomized trial. PLoS ONE 2014; 9: e100084.

    Article  Google Scholar 

  33. 33

    Chrysohoou C, Panagiotakos DB, Pitsavos C, Das UN, Stefanadis C . Adherence to the Mediterranean diet attenuates inflammation and coagulation process in healthy adults: The ATTICA Study. J Am Coll Cardiol 2004; 44: 152–158.

    Article  Google Scholar 

  34. 34

    Neale EP, Batterham MJ, Tapsell LC . Consumption of a healthy dietary pattern results in significant reductions in C-reactive protein levels in adults: a meta-analysis. Nutr Res 2016; 36: 391–401.

    CAS  Article  Google Scholar 

  35. 35

    Givertz MM, Postmus D, Hillege HL, Mansoor GA, Massie BM, Davison BA et al. Renal function trajectories and clinical outcomes in acute heart failure. Circ Heart Fail 2014; 7: 59–67.

    CAS  Article  Google Scholar 

  36. 36

    Gomberg-Maitland M, Shah SJ, Guazzi M . Inflammation in heart failure with preserved ejection fraction: time to put out the fire. JACC Heart Fail 2016; 4: 325–328.

    Article  Google Scholar 

  37. 37

    Kitzman DW, Upadhya B . Heart failure with preserved ejection fraction: a heterogenous disorder with multifactorial pathophysiology. J Am Coll Cardiol 2014; 63: 457–459.

    Article  Google Scholar 

  38. 38

    Borlaug BA, Paulus WJ . Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. Eur Heart J 2011; 32: 670–679.

    Article  Google Scholar 

  39. 39

    Paulus WJ, Tschope C . A novel paradigm for heart failure with preserved ejection fraction: comorbidities drive myocardial dysfunction and remodeling through coronary microvascular endothelial inflammation. J Am Coll Cardiol 2013; 62: 263–271.

    Article  Google Scholar 

  40. 40

    Fito M, Estruch R, Salas-Salvado J, Martinez-Gonzalez MA, Aros F, Vila J et al. Effect of the Mediterranean diet on heart failure biomarkers: a randomized sample from the PREDIMED trial. Eur J Heart Fail 2014; 16: 543–550.

    CAS  Article  Google Scholar 

  41. 41

    Koloverou E, Esposito K, Giugliano D, Panagiotakos D . The effect of Mediterranean diet on the development of type 2 diabetes mellitus: a meta-analysis of 10 prospective studies and 136,846 participants. Metabolism 2014; 63: 903–911.

    CAS  Article  Google Scholar 

  42. 42

    Lam CS, Solomon SD . The middle child in heart failure: heart failure with mid-range ejection fraction (40-50%). Eur J Heart Fail 2014; 16: 1049–1055.

    Article  Google Scholar 

  43. 43

    Delgado-Lista J, Perez-Martinez P, Garcia-Rios A, Alcala-Diaz JF, Perez-Caballero AI, Gomez-Delgado F et al. CORonary Diet Intervention with Olive oil and cardiovascular PREVention study (the CORDIOPREV study): rationale, methods, and baseline characteristics: a clinical trial comparing the efficacy of a Mediterranean diet rich in olive oil versus a low-fat diet on cardiovascular disease in coronary patients. Am Heart J 2016; 177: 42–50.

    CAS  Article  Google Scholar 

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We thank the rest of the field investigators of the study: Mrs Andria Christofi (dietary evaluation), Mrs Vasiliki Sinopoulou (dietary evaluation), Mrs Sophia Paspaliari (dietary evaluation), Dr Christina Maria Kastorini (dietary evaluation), Mrs Catherine Paraskeva (follow-up ecaluation), Mrs Lemonia Klaogirou (follow-up evaluation), and Mrs Hara Kossifa (follow-up evaluation).

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Correspondence to C Chrysohoou.

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Kouvari, M., Chrysohoou, C., Aggelopoulos, P. et al. Mediterranean diet and prognosis of first-diagnosed Acute Coronary Syndrome patients according to heart failure phenotype: Hellenic Heart Failure Study. Eur J Clin Nutr 71, 1321–1328 (2017).

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