A Structured Narrative Review of Contemporary Dietary Strategies Following Acute Coronary Syndromes

Acute coronary syndromes (ACS) remain a leading cause of morbidity and mortality worldwide. Although a Mediterranean-style diet is recommended for secondary prevention following ACS, patients are increasingly interested in alternative dietary approaches. This structured narrative review critically compares the evidence supporting eight dietary patterns for secondary prevention following ACS.

A structured literature search of PubMed/MEDLINE was performed from database inception through October 2025. Randomized controlled trials evaluating Mediterranean, Dietary Approaches to Stop Hypertension (DASH), plant-based, intermittent fasting, low-carbohydrate/ketogenic, Palaeolithic, Atkins, and Carnivore diets in adults following ACS were prioritised. Where randomized evidence in post-ACS populations was unavailable, evidence from broader cardiovascular populations was included to provide clinical context. Primary outcomes were major adverse cardiovascular events and cardiovascular mortality, while secondary outcomes included low-density lipoprotein cholesterol (LDL-c), blood pressure, body weight, and adherence to dietary interventions.

Twenty-eight studies met the inclusion criteria, comprising five Mediterranean-style diet studies, seven DASH studies, four vegetarian/vegan diet studies, four intermittent fasting studies, four low-carbohydrate studies, two Atkins studies, one Palaeolithic diet study, and one Carnivore diet study. Despite the emergence and popularity of other diets, the Mediterranean diet demonstrated the strongest and most consistent evidence for reducing recurrent cardiovascular events and improving cardiovascular risk factors following ACS. DASH and plant-based dietary patterns improved cardiovascular risk factors but lacked robust post-ACS outcome data. Evidence supporting intermittent fasting, low-carbohydrate/ketogenic, Palaeolithic, Atkins, and Carnivore diets was limited, with few randomized studies and insufficient evidence to support their routine use in secondary prevention.

A Mediterranean-style diet remains the dietary pattern supported by the strongest evidence for secondary prevention following ACS. Until further pragmatic randomized trials are available, clinicians should continue recommending Mediterranean-style dietary patterns while individualising dietary advice according to patient preferences, cultural practices, and long-term adherence.