Letter by Burillo-Putze et al regarding article, "acute coronary syndrome and khat herbal amphetamine use: an observational report".

Letter by Burillo-Putze et al Regarding Article, “Acute Coronary Syndrome and Khat Herbal Amphetamine Use: An Observational Report” To the Editor: We have read with interest the article by Ali et al and would like to offer some comments on acute coronary syndrome (ACS) associated with khat consumption from the point of view of its clinical impact in Europe.1 The prevalence of khat use in the European Union is seemingly low, but in the United Kingdom, Holland, and Norway2 it has been reported among firstand secondgeneration immigrants from East Africa and the Arabian Peninsula, where khat use is socially accepted and common. In addition, seizures of khat by European law enforcement officers have increased, with amounts approximating almost half those of cocaine.3 At present, the prevalence of khat consumption by the nonimmigrant population is still unknown, but the recent surge of grow shops and smart shops, particularly accessible via the internet, and the promotion of khat as a natural substance traditionally used in certain cultures, make it more likely to gain ground in our setting.4 The results presented by Ali et al, along with the probable unfamiliarity of doctors attending patients with cardiovascular disorders after recreational use of new substances, warrant an alarm call to include possible khat consumption in the medical history of patients with ACS, especially among those 40 years of age. Given the inability of qualitative and semiquantitative tests usually available in the Emergency Department to detect khat, a negative result for cocaine or amphetamine use does not allow us to rule out khat or its synthetic derivatives such as mephedrone. Finally, we do not agree with the affirmation that -blockers can be used in ACS after cocaine consumption; the studies cited by Ali et al do not refer to -blocker use for acute clinical situations, but rather to stable inpatients or patients at discharge. Currently, there is no scientific evidence to support the immediate administration of -blockers for ACS associated with cocaine consumption.5 Given the similarity between the adrenergic effects of amphetamine derivatives and cocaine, we believe other therapeutic options should be considered before prescribing -blockers for ACS induced by khat.