**4. Amphetamines and derivatives: ecstasy and methamphetamines**

These synthetic drugs are used for their psychostimulant effects. They had been first used by German army during the Second World War for these sought effects. Later, their cardiovascular dangers were revealed.

The main mechanism of action is an indirect sympathomimetic effect by releasing norepinephrine, dopamine, and serotonin from central and autonomic nervous system terminals, leading, as in cocaine intoxication, to an increase in the central and peripheral catecholamine concentrations [53].

High catecholamine levels are known to be cardiotoxic, causing vasospasm, tachycardia, and hypertension, leading to increased myocardial oxygen demand and myocyte necrosis and fibrosis [54].

The association of these stimulants and sudden cardiac death is well established. A recent histopathological study showed that among 100 methamphetamine poisoning-related deaths, 68% had cardiac lesions [55]. In this context, death can result either from lethal aortic dissection or from ventricular arrhythmia. This latter may complicate either type 1 and type 2 myocardial infarctions or methamphetamine-induced cardiomyopathy and is triggered by catecholamine excess [56]. Furthermore, according to an interesting recent study, among 230 amphetamine abuser patients, 43% presented with sinus tachycardia and 3.5% presented with cardiac arrhythmias: ventricular tachycardia, premature atrial beats, paroxysmal supraventricular tachycardia, and premature ventricular beats [57].
