From January 1979 to February 1989, 22 cocaine addicts were studied at necropsy. The 22 patients were divided into 2 groups: death associated with increased cocaine levels at necropsy (13 patients, aged 23 to 45 years [mean 32], and mean total blood cocaine level, 0.36 mg/dl) and noncocaine-related death (9 patients, aged 15 to 50 years [mean 32]). Of the 22 patients, 17 were men and 5 were women; 19 were black and 3 were white. Gross examination in the 22 patients disclosed that 8 patients (36%) had 1 or more of the 4 major (left main, left anterior descending, left circumflex, and right) coronary arteries narrowed at some point greater than 75% in cross-sectional area by atherosclerotic plaque. In 17 cases, the 4 major epicardial coronary arteries were divided into 805 five-mm long segments and a histologic section was prepared from each segment: of the 12 patients with a cocaine-related death, 41 (8%) of 544 five-mm coronary segments were narrowed 76 to 100% and 106 segments (19%) were narrowed 51 to 75% in cross-sectional area by plaque. Of the 5 cocaine addicts who did not die from cocaine overdose, 8 (3%) of 261 five-mm coronary segments were narrowed 76 to 100% and 19 segments (7%) were narrowed 51 to 75% in cross-sectional area by plaque. The frequency of coronary artery disease was greater in patients dying with cocaine in their blood at necropsy compared to those whose death was not cocaine related.(ABSTRACT TRUNCATED AT 250 WORDS)