Abstract
Background: Acute coronary syndrome (ACS) encompasses ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and unstable angina. While optimal medical therapy (OMT) is central to secondary prevention, lifestyle interventions-particularly dietary modification-remain underutilised despite their potential impact on long-term outcomes. Objective: To review the current evidence regarding dietary interventions post-ACS, their implementation, adherence, and effects on cardiovascular risk factors and clinical outcomes. Methods: A narrative literature review was performed using PubMed, including studies published in English from 2000 onwards. Keywords included "acute coronary syndrome," "diet," "cardiovascular disease," "outcomes," "adherence," "wine," and "intermittent fasting," combined with Boolean operators AND/OR. Animal studies were excluded. The latest search was conducted in October 2025. Results: Mediterranean-style diets, when combined with OMT and lifestyle interventions (exercise, smoking cessation, alcohol moderation), consistently improve cardiovascular risk factors and reduce recurrent ischemic events and mortality. Clinical trials and cohort studies demonstrate long-term benefits, including reductions in all-cause mortality and major adverse cardiovascular events, particularly in patients adhering to structured dietary programmes within cardiac rehabilitation. Evidence for other dietary modifications, including low-fat diets, increased fibre, antioxidant supplementation, and intermittent fasting, was more limited, often derived from small or short-term studies focusing on surrogate endpoints. Real-world adherence to dietary guidelines remains suboptimal, especially in high-risk and obese populations. Preliminary studies suggest intermittent fasting and moderate red wine consumption may confer additional cardiovascular benefits, though larger, long-term trials are needed. Conclusions: Dietary modification is a key, yet underutilised component of secondary prevention post-ACS. A Mediterranean-style, whole-food diet integrated with OMT and supported by structured cardiac rehabilitation programmes offers the most evidence-based strategy to improve risk factor control and long-term outcomes. Future research should focus on pragmatic, long-term trials assessing hard cardiovascular endpoints and implementation strategies to enhance adherence across diverse populations.