Cocaine is an extremely powerful reinforcing psychostimulant with highly addictive properties. Over the last few decades, cocaine addiction has attained epidemic proportions in North America, imposing a tremendous burden on society and the health care system. The cardiovascular complications of cocaine abuse are adrenergic mediated and range from cocaine-associated acute coronary syndromes to aortic dissection and sudden cardiac death. Concomitant alcohol and cigarette smoking exacerbate the cardiotoxicity of cocaine. This contemporary review discusses the spectrum of cardiac complications arising from cocaine use, operant pathophysiologic mechanisms and controversies surrounding the pharmacotherapy of cocaine-associated acute coronary syndromes.