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Objective: This study aimed to assess the protective role of dietary habits and Mediterranean diet adherence in first acute myocardial infarction in patients enrolled in the multicenter and multiethnic FAMI (First Acute Myocardial Infarction) study., Methods: In this study we analyzed a multiethnic case-control population of 1478 individuals (858 from Europe and 620 from China): 739 patients with ST-elevation myocardial infarction (STEMI) without previous history of coronary artery disease who were admitted to the Emergency Department within 6 h of symptoms onset, and 739 age- and sex-matched healthy controls. Dietary habits were collected with a food frequency questionnaire from which we calculated the FAMI Mediterranean Diet Score, according to the adherence to Mediterranean diet., Results: European patients with STEMI had significantly lower adherence to Mediterranean diet than controls. Among Chinese populations, there was no association between FAMI Mediterranean Diet Score and STEMI prevalence. The distribution of the main food types suggested that our questionnaire was not an effective tool to study dietary habits in the Chinese population. In the European population, higher adherence to Mediterranean dietary pattern was associated with a protective effect on the risk of STEMI, independently of global cardiovascular risk factor profile. Furthermore, high fruit and vegetable consumption was associated with a significant reduction of STEMI risk., Conclusions: The study found a protective effect of the Mediterranean diet and high fruit and vegetable consumption on the risk of first STEMI, regardless of traditional cardiovascular risk factors in the European population., (Copyright © 2019 Elsevier Inc. All rights reserved.)