Cardiovascular Conditions and Symptoms in Deaths Attributed to Acute Stimulant Toxicity

The underlying cause of deaths attributed to acute stimulant (methamphetamine or cocaine) toxicity is poorly understood, although cardiovascular events are believed to contribute.

We analyzed psychological autopsy data from acute stimulant toxicity deaths in San Francisco from 2022 to 2023. Sources included vital records, autopsies, medical records, and mixed-methods interviews with informants (eg, family and friends) who knew decedents in the year preceding death. We compared sociodemographic characteristics and cardiovascular measures (autopsy, ECG, echocardiogram, or laboratory abnormalities; diagnoses; acute care visits; symptoms) by fentanyl involvement. Age was skewed and compared with a Wilcoxon rank-sum test. Proportions were compared with χ² or Fisher exact tests. Qualitative thematic analyses identified themes related to cardiovascular health in interviews.

Among 101 deaths, 70 involved stimulants without opioids and 31 also involved fentanyl. Median age at death was higher among stimulant without opioids compared with fentanyl-involved decedents (58 versus 50 years; P=0.02). A plurality were White (44%), and 36% were Black. Most (69%) were unhoused or marginally housed. Cardiovascular conditions were identified in records among 93% of stimulant without opioids and 71% of fentanyl-involved decedents (P<0.01), and symptoms were reported by informants for 76% of stimulant without opioids and 52% of fentanyl-involved decedents (P=0.02). Specific conditions more prevalent among stimulant without opioid decedents were cardiac enlargement (P=0.04), coronary artery disease (P=0.01), prolonged QTc interval (P=0.03), and hypertension (P=0.02). Themes from 140 informant interviews included family history of cardiovascular disease, cardiovascular symptoms, comorbid conditions, reluctance to seek care, and poor health contributing to social isolation.

Premortem cardiovascular conditions and symptoms were common among stimulant decedents and were more prevalent among deaths attributed to stimulants without opioids compared with those involving fentanyl. In addition to opioid overdose prevention efforts, people who use stimulants might benefit from aggressive prevention and treatment of cardiovascular disease.