Response to Letters Regarding Article, “Acute Coronary Syndrome and Khat Herbal Amphetamine Use: An Observational Report”

We appreciate the insightful comments in the 3 accompanying letters regarding our recent article.1 The letters highlight important issues with regard to khat and acute cardiac events. In the first letter, we thank Drs Aleryani and Al-akwa for suggesting potentially additional mechanisms whereby khat chewing has cardiovascular effects in addition to those already described in our article, which are coronary artery vasoconstriction, elevation in blood pressure, and possibly hypercoagulable state. The authors suggest khat-induced oxidative stress and apoptosis as well as pesticide exposure of khat before it is “freshly” chewed as possibly contributing to these detrimental effects. Although to date there is lack of definitive data linking pesticides exposure to acute coronary syndrome risk, we concur with the authors that further studies evaluating the various aspects of khat use and its cardiovascular effects are urgently needed. We also concur with the authors that although Cathinone, the main active substance in khat, is very similar to amphetamine; however, it is not identical to it. The term “herbal or natural amphetamine” we used for khat was first introduced in the literature by Kalix et al2 in 1991, to highlight its similarity to amphetamine. In the second letter, we appreciate Dr Burrilo-Putze's description of the clinical impact of khat use in Europe. Indeed, cardiovascular complications of khat use have been reported in Europe and more recently in Australia,3; …