Abstract Two young patients with dilated cardiomyopathies associated with long-term use of cocaine are described. A 42-year-old male cocaine abuser with normal coronary arteries experienced recurrent myocardial infarction, with development of a dilated, globally hypocontractile left ventricle. The second patient, a 28-year-old woman with a prominent history of inhaling vaporized cocaine (“free-basing”), presented with symptoms and signs of biventricular heart failure and was found to have a dilated cardiomyopathy. The clinical spectrum of cocaine cardiotoxicity is reviewed, and pathophysiologic mechanisms of cocaine-induced cardiomyopathy are discussed. Long-term cocaine use may cause dilated cardiomyopathy and recurrent myocardial infarction, even in the absence of atherosclerotic epicardial coronary artery disease.