Substance use, including the use of tobacco, alcohol, and illicit drugs such as cocaine and cannabis, significantly increases cardiovascular (CV) risk and contributes to premature atherosclerotic disease development. Cardiologists should routinely screen for depression using empathetic, non-stigmatizing approaches and validated tools to improve patient outcomes through timely intervention and referral.

Despite factors such as lack of time, a degree of embarrassment or discomfort, or the perception that this is an issue belonging to other specialties, problematic substance use constitutes an aggravating factor in traditional CV risk scores and should be a dimension addressed during cardiology consultations, emphasized by Eliane Sasovsky, MD, a member of the Cardiovascular Prevention Council of the Argentine Society of Cardiology, during a roundtable at the 51st Argentine Congress of Cardiology held from October 15 to 17, 2025.

“This is a topic that sometimes makes us uncomfortable. There are many prejudices, and we do not always like to address them. However, we need to step away from this position, assume that substance use modifies risk for CV, and understand that addressing it is beneficial for health of the patients. The cardiologist is often the patient ’s main reference physician,” she said.

Speaking with Medscape’s Spanish edition, Sasovsky said, “We are more accustomed to asking about tobacco, but it is important to consider other substances.”

In her presentation, she noted that different drugs of abuse develop risk for CV mediated by multiple mechanisms, including direct toxicity, myocardial inflammation, sodium channel blockade, endothelial dysfunction, prothrombotic effects, and increased catecholamine release. In adjusted models, recreational use or consumption of tobacco, alcohol, cocaine, amphetamines, cannabis, and other drugs increases the risk for premature atherosclerotic CV disease by 1.5- to 2.7-fold, according to a 2021 study. “Between 15% and 30% of people with acute coronary syndrome younger than 45 years have drug metabolites in their blood. It is chilling,” she said.

Sasovsky outlined seven keys to addressing this issue in the cardiology consultation.

Seven Keys

Normalize the question. When asking about substance use, make it clear that this is a routine question for all patients. For example, explain that “In cardiology, we always ask about alcohol, tobacco, and other substances because they influence the heart.” Each clinician finds their own approach, but it should be empathetic. One option is to ask about the past year or month; assess whether there are physical, mental, or social repercussions; and determine whether a referral is needed.

Use descriptive and non-stigmatizing language. Refer to “substance use” or “consumption,” not “addiction” or “drugs.”

Start with the most common substances, such as tobacco and alcohol, and then progress gradually.

Explain the medical purpose.

Use validated tools for objectification. Examples include the short version of the Alcohol Use Disorders Identification Test, which includes three questions: How often do you drink alcoholic beverages? How many drinks do you usually consume on a typical day? How often do you consume six or more drinks on one occasion? Each question was scored from 0 to 4 points, with positive results defined as a score of ≥ 4 in men and ≥ 3 in women.

Another option is the Alcohol, Smoking and Substance Involvement Screening Test of the World Health Organization, which takes 10-15 minutes and allows the detection of experimental, risky, or probable dependence on tobacco, alcohol, cannabis, cocaine, stimulants, inhalants, sedatives, hallucinogens, and opioids.

Acknowledge and thank the patient for their honesty. A possible phrase is: “I appreciate sharing this information with me because it helps me take better care of your health.”

Document without judgment and offer help without pressure. It is important to record substance use in the medical record using respectful, non-stigmatizing but descriptive language so that another clinician can also use the information.

Sasovsky proposed reassessing the situation at each visit, exploring motivation for use, negotiating small goals, and referring when there is dependence or comorbidity. “We need longitudinal follow-up and team-based work, keeping in mind that we have colleagues who specialize in this area and to whom we can refer and ask for help,” she said.

Public Health Issue

When consulted by Medscape’s Spanish edition, two physicians from different generations and professional backgrounds, who had published studies on the effect of addictions on CV, agreed on the importance of addressing problematic substance use during medical history.

“One of the pillars of evidence-based medicine lies in preferences of the patient based on the principle of autonomy. In order to comply with these principles, any aspect that could influence the patient’s health to a greater or lesser degree must be addressed diligently, which implies confronting taboos and the discomfort that this entails,” said Ezequiel García-Ballestas, MD, a member of the Center for Biomedical Research of the Faculty of Medicine at the University of Cartagena in Cartagena, Colombia, and the lead author of a review article on cocaine use and CV disease in young adults.

The responsibility of the cardiology specialist in this area is even greater because the population perceives their higher level of competence, which increases credibility and reduces the influence of psychological biases that fuel taboos, García-Ballestas said. The cardiologist “has tools aimed at addressing cocaine use and other substances and at preventing the harmful effects of use of these substances on the CV system. However, it will still require collective effort to increase awareness among health professionals, leave stigmatization behind, and abandon prejudice.”

José Milei is a senior researcher at the National Scientific and Technical Research Council of Argentina and an emeritus professor of medicine at the Faculty of Internal Medicine of the University of Buenos Aires, Buenos Aires, Argentina. Milei, who also leads the Laboratory of Atherosclerosis and Hypertension at the Institute of Cardiological Research “Prof. Dr. Alberto C. Taquini,” a research center affiliated with the University of Buenos Aires and the National Scientific and Technical Research Council, noted that clinicians should not hesitate to ask about behaviors that may affect the risk for CV, particularly in individuals younger than 45 years. “Appropriately directed questions about substance use are now just as important as asking about diabetes, hypertension, or smoking,” he said.

In general, all addictions cause symptoms related to the CV system, although most are nonspecific, such as hypertension, hypotension, and tachycardia, and in severe cases, syncopal episodes, or even acute myocardial infarction, he noted.

In 2000, Milei was part of a cardiology team that performed imaging studies and endomyocardial biopsy with light, electron, and histochemical microscopy of the heart of the then-retired football star, Diego Maradona.

At the time, Maradona was 39. Months earlier, he had narrowly survived hemodynamic decompensation complicated by polymorphic ventricular tachycardia and had a 17-year history of habitual intranasal cocaine use.

The analysis reported “unquestionable evidence” that the dilated cardiomyopathy resulted from the direct toxic effects of cocaine on the myocardium. The study, published in Revista Argentina de Cardiología, the official journal of the Argentine Society of Cardiology, preserved patient anonymity by referring to him only as “a young patient” and was widely regarded as a wake-up call.

Since then, the problem of illicit drug use has continued to grow and “has become a serious public health issue,” said Milei. “The medical history taken by the clinician, whether during a scheduled consultation or in acute pathology, requires adding questions about the presence of addictions, given that they worsen clinical presentations and risks linked to CV disease.”

Milei is currently developing an experimental rodent model to document and visually record the chronic anatomical, physiologic, chemical, and behavioral effects of exposure to heat-volatilized drugs, including cocaine base paste, also known as paco. This project is intended for educational purposes. He concluded that the use of this substance in Argentina has increased by more than 200% in recent years.

All participants declared having no relevant financial conflicts of interest. 

This story was translated from Medscape’s Spanish edition.