Pathological cardiac changes associated with recreational drug-related sudden cardiac death: a systematic review

Background Recreational drug use has been associated with sudden cardiac death (SCD), but the pathological cardiac findings reported at autopsy vary among different substances. This systematic review aims to highlight the pathological findings of the most common recreational drugs associated with SCD. We conducted the initial literature search from March to April 2025. We conducted an updated search in September 2026 in PubMed, Web of Science, and Scopus to identify newly published eligible studies. Eligible studies included case reports, case series, and retrospective case series published in English that reported relevant pathological cardiac findings in recreational drug-related SCD. Studies without relevant autopsy findings or without a cardiac cause of death were excluded. Results Eighteen studies met the eligibility criteria, involving alcohol, cocaine, methamphetamine, novel opioids, nicotine, cannabis, and anabolic steroids. Cardiac enlargement was the most frequently reported pathological finding, followed by myocardial fibrosis. Myocardial infarction (MI) appeared in chronic cocaine and amphetamine users, with more prolonged effects in amphetamine users. Coronary artery disease was documented among cocaine and marijuana users, which can be differentiated by history and associated findings. At the same time, dilated cardiomyopathy was identified in studies involving alcohol, methamphetamine, and novel opioids. Conclusion In cases of recreational drug-related SCD, a complete forensic examination using police records, medical reports, histological examination, and toxicological analysis is important to reach the diagnosis. The reviewed evidence indicates that cardiac pathology may provide important supportive findings for postmortem interpretation.