Fatal intoxications and inherited cardiac disorders in the young: where to draw the line?

Sudden cardiac death represents a significant public health concern and is one of the leading causes of early mortality worldwide. The escalating use of illicit drugs, approximately 269 million people in 2018, represents a growing public health. Some of these drugs are stimulants that may have multiple effects on the cardiovascular system including the cardiac rhythm, then substance abuse increases the risk of sudden death. For instance, drugs like cocaine and methamphetamine, may be responsible for myocardial infarction as well as occlusive coronary thrombosis with acute infarction. The consequences of such occurrences are far-reaching, with considerable effects not only on the victims but also on their families. Sudden cardiac death presents considerable forensic diagnostic challenges, particularly in the presence of high but non-lethal drug levels increasing the possibility of a genetic predisposition to malignant arrhythmogenic events. Our review aims to discuss the complex relationship between illicit drugs and congenital cardiac disorders, stressing the forensic issues deriving from their interaction and from the differential diagnosis. Indeed, especially when a non-lethal dose of illicit drug in presence of ambiguous microscopic findings is reported, being able to discriminate between a toxic sudden death (entailing criminal implications for the drug dealer) and a natural sudden death is a forensic issue of upmost importance.