Serious Arrhythmias Playing Video Games 'Extremely Rare'

Marilynn Larkin

August 07, 2023

Young people diagnosed with a genetic heart disease (GHD) predisposing them to ventricular arrhythmia are at very low risk for a cardiac event while playing video games or other electronic games, provided their condition is properly treated, say researchers based on their large, single-center study.

Among more than 3300 patients in the study with such a genetic vulnerability, just 6 — or less than 0.2% — experienced an electronic gaming-associated cardiac event.

A previous study had concluded that e-gaming, particularly with war games, might trigger potentially fatal arrhythmias in some vulnerable children. That study "sparked controversy in the field, with both clinicians and patients wondering whether electronic gaming is safe for patients with GHDs," Michael J. Ackerman, MD, PhD, of Mayo Clinic in Rochester, Minnesota told Cardiology.

Ackerman and colleagues conducted the current study, published online today in the Journal of the American College of Cardiology, to determine just how often e-gaming triggered cardiac events (CE) in these patients — and who was most at risk.

"Extremely Low" Risk

The investigators looked at records from all patients evaluated and treated at Mayo Clinic’s genetic heart rhythm clinic from 2000 to 2022. They identified those with a history of playing electronic games at the time of their CE, defined here as such an event occurring before diagnosis, or breakthrough cardiac event (BCE), meaning an event occurring after diagnosis.

A total of 3370 patients with a GHD (55% female) were included in the analysis. More than half (52%) were diagnosed with long-QT syndrome (LQTS). The remainder had various GHDs including, among others, catecholaminergic polymorphic ventricular tachycardia (CPVT) or hypertrophic cardiomyopathy (HCM).

The mean age at first evaluation was 27; 14% of the participants were age 6 or younger, 33% were age 7 to 20, and 53% were 21 or older. Most patients in each of the three age groups were diagnosed with either LQTS or CPVT.

Of the 3370 GHD patients, 1079 (32%) had a CE before diagnosis.

Six patients (0.5%) had a CE in the setting of e-gaming, including 5 for whom it was the sentinel CE. Five also had CEs in settings not involving e-gaming. Their average age at the time of the CE was 13.

Three of the six patients were diagnosed with CPVT (including two CPVT1 and one CPVT2). Of the others, one was diagnosed with LQT1, one with ventricular fibrillation triggered by premature ventricular contractions, and one with catecholamine-sensitive right-ventricular outflow tract (RVOT) ventricular tachycardia (VT).

After appropriate treatment, none of the six experienced a BCE during follow-ups ranging from 7 months to 4 years.

Among the full cohort of 3370 patients with GHD, 431 (13%) experienced one or more BCE during follow-up. Of those, one with catecholamine-sensitive RVOT-VT experienced an e-gaming–associated BCE.

"Although anecdotal e-gaming–associated cardiac events, including [sudden cardiac death], have been reported, the absolute risk is extremely low," the authors write.

"Although there are no clear health benefits associated with e-gaming," Ackerman said, "the risk of sudden death should not be used as an argument in an effort to curtail the amount of time patients spend e-gaming."

Furthermore, he added, e-gaming is important to some patients' quality of life. If patients are "properly diagnosed, risk-stratified, and treated, it is okay to engage in e-gaming."

However, "given that e-gaming may pose some risks, especially when compounded with additional factors such as dehydration, sleep deprivation, and use of performance-enhancing substances such as energy drinks, patients need to be counseled on the potential adverse health consequences," Ackerman said.

"To this end," he added, "we are proponents of incorporating e-gaming status into the clinical evaluation and electronic health record."

"We would continue to urge common sense and individual risk assessment, with shared decision making, for those where this may be an issue," Claire M. Lawley, MBBS, PhD, Children's Hospital at Westmead, New South Wales, Australia, told Cardiology.

"Additionally, syncope during electronic gaming should prompt medical review," said Lawley, lead author of the study that that prompted Ackerman and colleagues to investigate the issue further.

Buddy System

Maully J. Shah, MBBS, led a study published in 2020 focusing on two case reports of syncope and potentially life-threatening ventricular arrhythmias provoked by emotional surges during play with violent video games. 

Nevertheless, "we do not restrict patients from participating in e-games," Shah, a pediatric cardiac electrophysiologist at the Cardiac Center at Children's Hospital of Philadelphia, told the Cardiology. "We inform them about the available data regarding the very rare but possible occurrence of an event from e-gaming so that they can make an informed decision."

Shah agreed that, "even in children not known to have a cardiac condition, syncope associated with emotional responses during violent video games should prompt cardiac evaluation, similar to exercise-induced syncope."

If a patient wishes to play e-games, clinicians should ensure medication compliance and recommend a "buddy" system. "Don’t be alone while playing," she said.

"The present study and previous reports make one pause to think whether these CEs and catecholaminergic drives can occur with sports only. If we now consider electronic gaming as a potential risk, what other activities need to be included?" write the authors of an accompanying editorial, led by Shankar Baskar, MD, Cincinnati Children's Medical Center, Cincinnati, Ohio.

"A catecholaminergic drive can occur in many settings with activities of daily living or activities not considered to be competitive," the editorial notes.

"Ultimately these events [are] rare," it continues, "but they can have life-threatening consequences, and at the same time they might not be altogether preventable and, as in electronic gaming, might be an activity that improves quality of life, especially in those who might be restricted from other sports."

Ackerman discloses consulting for Abbott, Boston Scientific, Bristol-Myers Squibb, Daichii-Sankyo, Invitae, Medtronic, Tenaya Therapeutics, and UpToDate. Ackerman and Mayo Clinic have license agreements with AliveCor, Anumana, ARMGO Pharma, Pfizer, and Thryv Therapeutics. The other co-authors report no relevant relationships. Baskar et al report no relevant relationships. Shah discloses she is a consultant to Medtronic.

J Am Coll Cardiol. Published online August 7, 2023. Abstract, Editorial

Follow Marilynn Larkin on Twitter:  @MarilynnL .

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