• Drug Interactions
• Heart Failure
• Outcome Assessment, Health Care
• Ethics, Medical
• Acute Coronary Syndrome

The burden of recreational drug use has increased dramatically over the last decade in Europe and at a global level, with an estimated 284 million people aged 15–64 years using drugs worldwide in 2020.1 2 Many of these drugs have cardiovascular effects, which may be underappreciated both by those taking them and by clinicians. Use of stimulants such as cocaine and methamphetamines, for example, can cause sympathetic activation, increased myocardial oxygen demand, coronary vasospasm and thrombosis, as well as longer term effects such as arterial hypertension, accelerated atherosclerosis, and increased rates of sudden death.3 4 Cannabis exerts its effects through sympathetic stimulation and parasympathetic depression.5 Opioids, well known to cause potentially fatal respiratory depression, also promote vasodilatation, hypotension, and bradycardia through acute opioid receptor-mediated effects, and an increased adrenergic state in withdrawal. Long-term oral opioid use is a major health and societal problem, a common cause of accidental death, and is increasingly recognised for an association between synthetic agent use and sudden death, potentially mediated by prolongation of the QT interval.6 Overall cardiac morbidity and mortality rates have been shown to be significantly increased among people who use recreational drugs.7 ,8 Current epidemiological and outcome data, however, are based on self-reported drug use, which is likely to result in heavily selected populations and biased study findings.

In this issue of Heart, Pezel et al report on their prospective observational study of the prevalence of recreational drug use in 1499 patients admitted to 39 intensive cardiac care units across France during the …