Association of the Mediterranean Diet, Physical Activity and Related Lifestyle Factors on the Mortality and Major Adverse Cardiovascular Events in Patients with Coronary Heart Disease: A Systematic Review and Meta-Analysis.
Greater Mediterranean diet adherence and habitual physical activity were associated with more favorable CHD outcomes, with physical activity showing particularly strong associations with reduced cardiovascular mortality.
Key Findings
Results
In a randomized comparison, the Mediterranean diet was associated with significantly lower risk of major adverse cardiovascular events compared to a low-fat diet in CHD patients.
HR for MACE was 0.72 (95% CI 0.54 to 0.96) in one randomized comparison of Mediterranean and low-fat diets
This finding was rated as moderate certainty using GRADE methodology
This represents a 28% relative reduction in MACE risk
Randomized evidence on combined dietary and activity programs was described as sparse
Results
Closer Mediterranean diet adherence was associated with lower all-cause mortality in CHD patients in observational studies.
Pooled HR for all-cause mortality was 0.74 (95% CI 0.60 to 0.90) with moderate heterogeneity (I2 = 44%)
This represents a 26% relative reduction in all-cause mortality risk
The association with cardiovascular mortality remained uncertain
Observational findings also supported inverse associations with MACE
Results were pooled using random-effects models
Results
Maintained or continued physical activity compared to persistent inactivity was associated with substantially lower all-cause mortality in CHD patients.
HR for all-cause mortality was 0.64 (95% CI 0.55 to 0.74) for maintained or continued physical activity versus persistent inactivity
Heterogeneity was low at I2 = 29%
This represents a 36% relative reduction in all-cause mortality risk
MACE findings for habitual physical activity generally favored lower risk
Results
Physical activity was associated with a particularly large reduction in cardiovascular mortality among CHD patients.
HR for cardiovascular mortality was 0.42 (95% CI 0.28 to 0.64) for maintained or continued physical activity versus persistent inactivity
This represents a 58% relative reduction in cardiovascular mortality risk
Heterogeneity was high at I2 = 72%, indicating substantial variability across studies
The comparison was maintained or continued physical activity relative to persistent inactivity
Methods
The systematic review and meta-analysis included 40 reports representing at least 260,354 unique CHD patients across diverse study designs.
40 reports represented 34 data sources and at least 260,354 unique patients
Study designs comprised six randomized trials, 30 observational reports, and four comparative nonrandomized studies
Search covered PubMed, MEDLINE, Scopus, Embase, and CENTRAL from January 2015 through 15 June 2026
Risk of bias was evaluated with design-appropriate tools and certainty with GRADE
Comparable hazard ratios were pooled using random-effects models; non-equivalent estimands were reported separately
Conclusions
Randomized evidence on exercise interventions or combined dietary and physical activity programs in CHD patients was sparse.
Only six randomized trials were identified across the entire review
Randomized evidence on exercise or combined dietary and activity programs was specifically characterized as sparse
The authors concluded that standardized, adequately powered trials are needed, especially for exercise and combined strategies
This evidence gap was identified as a key limitation of the current evidence base
What This Means
This research suggests that for people who have been diagnosed with coronary heart disease (CHD), both following a Mediterranean-style diet and staying physically active are linked to better survival and fewer serious heart events. The Mediterranean diet — rich in vegetables, fruits, whole grains, fish, and olive oil — was associated with roughly a 26–28% lower risk of death from any cause and serious cardiovascular events compared to less healthy dietary patterns. When comparing the Mediterranean diet directly to a low-fat diet in randomized trials, the Mediterranean diet showed a statistically significant advantage in reducing major adverse cardiovascular events.
The findings on physical activity were particularly striking. CHD patients who maintained or increased their physical activity levels had a 36% lower risk of dying from any cause and a 58% lower risk of dying from cardiovascular causes compared to those who remained persistently inactive. These associations held across a large body of evidence drawn from more than 260,000 patients. However, it is important to note that much of this evidence comes from observational studies, meaning researchers tracked people's behaviors and outcomes rather than randomly assigning them to different lifestyles, so the possibility that other factors influenced results cannot be ruled out.
This research suggests that lifestyle factors — specifically diet quality and physical activity — remain important even after a CHD diagnosis, not just for prevention. However, the authors caution that high-quality randomized trials specifically testing exercise programs and combined diet-plus-activity interventions in CHD patients are still lacking. Future research with standardized approaches is needed to more definitively guide clinical recommendations for this patient population.
Mo L, Qiu F, Liu Y, Zang Y, Chen C. (2026). Association of the Mediterranean Diet, Physical Activity and Related Lifestyle Factors on the Mortality and Major Adverse Cardiovascular Events in Patients with Coronary Heart Disease: A Systematic Review and Meta-Analysis.. Nutrients. https://doi.org/10.3390/nu18162589