Video games trigger dangerous cardiac arrhythmias in some children

Video game play can produce potentially fatal arrhythmias in susceptible children, including those not known to be at risk, and war games are a powerful trigger, an international case series and systematic review shows.

Nineteen patients experienced suspected or diagnosed ventricular arrhythmia while playing video games, six suffered cardiac arrest, and four died suddenly.

“Now that we have confirmed this new phenomenon, we need to ensure children and teens with underlying heart conditions remain safe in all of their activities,” Claire M. Lawley, MBBS, PhD, and Christian Turner, MBBS, both of Sydney Children’s Hospitals Network, Sydney, Australia dasherz.org | Medscape Cardiology.

“Any child or teenager who has a recent blackout, fainting, collapse or seizure should be evaluated by their local or GP [who] will then decide whether further testing is necessary,” they said.

The study was published online in the journal today heart rhythm.

Potentially deadly

“We had met a number of children in our practice with underlying heart rhythm problems who had worrisome events while playing electronic games,” Lawley and Turner explained. “After contacting some of our close colleagues in our own region, we realized that the phenomenon was not just limited to our own patients. We have therefore called on all our cardiac rhythm colleagues around the world to have similar experiences.”

For the study, electronic gaming was defined as “playing any game that uses electronics to create a system that a player can interact with,” including portable electronic games, console-based electronic games, computer-based games, and standalone systems such as an electromechanical arcade -games.

The team identified 22 patients (18 in international case series and 4 in a systematic review) who had suspected or proven ventricular arrhythmias while playing video games. The patients (19 men, 3 women) were between 7 and 16 years old.

Nineteen of the 22 patients had a diagnosis of proarrhythmia, and seven of these 19 (32%) had been diagnosed before their game event. Of the 7 diagnosed prior to the game event, 6 were prescribed a β-blocker, 2 had an ICD in situ, and 1 had an implantable cardiac monitor. In 12 (55%) patients the diagnosis was made after the game event.

Ten of these 19 patients with a proarrhythmic diagnosis had catecholaminergic polymorphic ventricular tachycardia (CPVT), 4 had long QT syndrome, 2 had undergone congenital heart surgery, 2 had idiopathic ventricular fibrillation, and 1 had coronary ischemia post-Kawasaki disease.

In 3 patients, including 2 of the deceased, the diagnosis is unknown.

Genetic test results were available for 17 (77%) patients, with potentially relevant genetic variants identified in 14.

Treatment varied depending on the severity of the episode presented, local institutional practice, and patient and family preferences. Notably, 5 of the 18 survivors had subsequent episodes of arrhythmia while playing electronic games, 4 of whom were taking antiarrhythmic drugs at the time.

Details about video games were known in 13 patients (59%); eight of the 13 (62%) played war games.

The authors propose that adrenergic stimulation plays a role in the pathophysiology of these arrhythmic events.

They note that the study’s “opt-in nature” may have resulted in an “underestimate of case numbers” and that they did not address events among older video gamers. Also, no information was available on possible confounders such as additional medical diagnoses, sleeping habits, and stimulant use.

Nonetheless, they warn that e-gaming could be promoted under the false premise that it could offer a safer alternative to higher-risk sports.

“In the past, cardiac rhythm specialists around the world had to educate children with certain cardiac arrhythmias and their families about safe exercise,” Lawley and Turner said. “Now we need to educate them about safe electronic gaming activities as well.”

Greater awareness required

Elizabeth DeWitt, MD, medical director of the surgical electrophysiology program at Boston Children’s Hospital and assistant professor of pediatrics at Harvard Medical School, commented on the study for theheart.org/Medscape Cardiology. “I am caring for a patient who went into cardiac arrest while playing an interactive film/video game, resulting in significant emotional upset, who was eventually diagnosed with CPVT. This event was the first cardiac symptom.

“As the authors point out, I have not usually specifically advised patients with known hereditary arrhythmia syndromes to be aware, and have focused more on the risk with exertion and emotional arousal in general,” she said. “It is important to highlight this topic and to further raise awareness.

“Unexplained syncope or palpitations during electronic gaming in previously healthy children or those with congenital heart defects should prompt a thorough evaluation to rule out arrhythmias, including detailed medical history, family history, EKG, and physical or pharmacological stress testing,” said DeWitt, who was not present involved in this study. “Patients with known inherited diagnoses of arrhythmias should be educated about the potential risk of arrhythmias associated with electronic gaming and alternative recreational activities should be considered.”

A multicenter registry could track such cases and prospectively collect others from around the world “to determine if additional recommendations or treatment approaches beyond those described might be important,” she suggests.

“Exertion” reconsidered

Although this phenomenon is not common, it is becoming more common, notes study co-investigator Jonathan Skinner, MBChB, MD, also of the Sydney Children’s Hospitals Network.

“Having cared for children with arrhythmias for more than 25 years, I have been shocked to see the prevalence of this emerging presentation and to discover that a number of children have even died from it,” he said in a statement. “All employees are keen to spread the word about this phenomenon so that our colleagues around the world can recognize and protect these children and their families.”

In a related editorial, Johnathan Rast, BS, William White, MD, and Daniel Sohinki, MD, MSc, of Augusta University in Georgia, write that “in the modern era, ‘effort’ should be understood to include activities outside of traditional ones includes competitive sports. Appropriate counseling on the risks of intense video game play should be directed to children with a proarrhythmic cardiac diagnosis and to all children with a history of exertional syncope of undetermined etiology.”

“In addition,” they say, “any future screening programs aimed at identifying athletes at risk for malignant arrhythmias should include athletes being considered for participation in eSports.”

No funding sources were disclosed. The study authors and editors report no relevant financial relationships.

heart rhythm Published online October 11, 2022. Abstract, Editorial

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