Olive oil, increasingly consumed in the U.S., has been inversely associated with cardiovascular disease (CVD) risk. However, previous studies did not assess a broad spectrum of CVD outcomes, incorporated repeated annual dietary assessments, or distinguished between polyphenol-rich EVOO and common olive oil (COO), which lacks these compounds.

We assessed 7102 high-risk participants from the PREDIMED trial (57.5% women; aged 55-80 years), all free of CVD at baseline. Olive oil consumption was assessed annually, and cumulative average intakes of EVOO and COO were calculated. The primary outcome was a composite of myocardial infarction, stroke, peripheral arterial disease, heart failure, atrial fibrillation, or cardiovascular death, whichever occurred first. Individual outcomes were also evaluated. Time-dependent Cox models were adjusted for major confounders, including trial intervention arm.

Over a median follow-up of 4.7 years, 621 participants experienced at least one CVD event. Participants in the highest tertile of cumulative EVOO intake (mean: 49.2 g/d) had a 25% lower risk of the composite outcome (HR: 0.75; 95% CI: 0.60-0.94), with significant reductions in several individual CVD outcomes. In the decile analysis, the highest (mean: 60.9 g/d) versus lowest decile had a 48% lower risk (HR: 0.52; 95% CI: 0.35 to 0.79). COO consumption was not significantly associated with CVD risk when mutually adjusted for EVOO (HR _{per 10 g/d} : 0.93; 95% CI: 0.87-1.00).

High consumption of EVOO is associated with a substantial reduction in the risk of an outcome-wide composite of CVD events among high-risk individuals. In contrast, COO, which lacks polyphenols, showed weaker associations, highlighting the importance of differentiating olive oil types in CVD prevention strategies.

This trial was registered in the ISRCTN registry (ISRCTN 35739639): ISRCTN35739639 .