OBJECTIVE: To summarise our present knowledge on the Mediterranean diet in secondary prevention of CHD. DESIGN: Review of literature. SETTING: Adult coronary patients. SUBJECTS: CHD patients at high risk of cardiac death. RESULTS: The two main causes of death in these patients are sudden cardiac death (SCD) and chronic heart failure (CHF). The main mechanism underlying recurrent cardiac events is coronary thrombosis resulting from atherosclerotic plaque erosion or ulceration. The occurrence of thrombosis is usually associated with plaque weakness in relation to high lipid content of the lesion where cholesterol only represents a very small part compared with other lipids (i.e. fatty acids). Thus, the three main aims of the preventive strategy are to prevent coronary thrombosis, malignant ventricular arrhythmia and the development of left ventricular dysfunction (and CHF) and finally to minimise the risk of plaque erosion and ulceration. There is now a consensus about recommending the Mediterranean diet pattern for the secondary prevention of CHD because no other dietary pattern has been successfully tested so far in these patients. The most important aspect, in contrast with the pharmacological prevention of CHD (including cholesterol lowering), is that the Mediterranean diet results in a striking effect on survival. CONCLUSIONS: The traditional Mediterranean diet is effective in reducing both coronary atherosclerosis/thrombosis and the risk of fatal complications such as SCD and heart failure.