The case of a 31-year-old man who died suddenly, with a history of drug abuse and no risk factors for coronary artery disease, is herein reported. Postmortem examination disclosed critical stenosis due to a fibrocellular atherosclerotic plaque complicated by occlusive thrombosis at the level of the left anterior descending coronary artery. Chemico-toxicological analysis revealed high levels of cocaine, tetrahydrocannabinol, and metabolites. When dealing with an acute coronary syndrome in young people, with or without a history of drug abuse, toxicological examination should always be performed to rule out unnatural causes of myocardial ischemia.