Electronic gaming can precipitate life-threatening cardiac arrhythmias in susceptible children whose predisposition may have been previously unrecognized, according to a new report in Heart Rhythm.
“Video games may represent a serious risk to some children with arrhythmic conditions; they might be lethal in patients with predisposing but often previously unrecognized arrhythmic conditions,” explained lead investigator Claire M. Lawley, MBBS, Ph.D., The Heart Center for Children, Sydney Children’s Hospitals Network, Sydney, Australia. “Children who suddenly lose consciousness while electronic gaming should be assessed by a heart specialist as this could be the first sign of a serious heart problem.”
The investigators performed a systematic review of literature and initiated a multisite international outreach effort to identify cases of children with sudden loss of consciousness while playing video games. Across the 22 cases they found, multiplayer war gaming was the most frequent trigger.
Some children died following a cardiac arrest. Subsequent diagnoses of several heart rhythm conditions put the children at continuing risk. Catecholaminergic polymorphic ventricular tachycardia (CPVT) and congenital long QT syndrome (LQTS) types 1 and 2 were the most common underlying causes.
There was a high incidence of potentially relevant genetic variants (63%) among the patients, which has significant implications for their families. In some cases, the investigation of a child who lost consciousness during video gaming led to many family members being diagnosed with an important familial heart rhythm problem. “Families and health care teams should think about safety precautions around electronic gaming in children who have a condition where dangerous fast heart rhythms are a risk,” noted Dr. Lawley.
The investigators attributed adrenergic stimulation related to the emotionally charged electronic gaming environment as the pathophysiological basis for this phenomenon. Electronic gaming is not always the “safe alternative” to competitive sports it is often considered. At the time of the cardiac incidents, many of the patients were in excited states, having just won or lost games, or were engaging in conflict with companions.
“We already know that some children have heart conditions that can put them at risk when playing competitive sports, but we were shocked to discover that some patients were having life-threatening blackouts during video gaming,” added co-investigator Christian Turner, MBBS, The Heart Center for Children, Sydney Children’s Hospitals Network, Sydney, Australia.
“Video gaming was something I previously thought would be an alternative ‘safe activity.’
The study notes that while this phenomenon is not a common occurrence, it is becoming more prevalent. “Having looked after children with heart rhythm problems for more than 25 years, I was staggered to see how widespread this emerging presentation is, and to find that a number of children had even died from it.
All of the collaborators are keen to publicize this phenomenon so our colleagues across the globe can recognize it and protect these children and their families,” noted co-investigator of the study, Jonathan Skinner, MBChB, MD, also from Sydney.
As an accompanying editorial Daniel Sohinki, MD, MSc, Department of Cardiology, Augusta University, Augusta, GA, U.S., and co-authors pointed out that “exertion should be understood to encompass activities outside of traditional competitive athletics. Appropriate counseling regarding the risks of intense video gameplay should be targeted in children with a pro-arrhythmic cardiac diagnosis, and in any child with a history of exertional syncope of undetermined etiology. Further, any future screening programs aimed at identifying athletes at risk for malignant arrhythmias should encompass athletes being considered for participation in e-sports.”
Electronic video games have assumed a prominent role in the daily activities of children and adolescents in the current era. In a small subset of children with underlying arrhythmogenic conditions, the adrenergic stimulation associated with the powerful emotions of electronic gaming may trigger life-threatening arrhythmias. Even in children not known to have a cardiac condition, syncope associated with emotional responses during violent video games should prompt cardiac evaluation.
Key Teaching Points
- •Syncope associated with exercise and strong emotional response raises suspicion for an adrenergic-mediated tachycardia.
- •In a small subset of children with underlying arrhythmogenic conditions, the adrenergic stimulation associated with the powerful emotions of electronic gaming may trigger life-threatening arrhythmias.
- •Similar to exertional syncope, cardiac symptoms such as syncope or palpitations brought on by powerful emotions during video gaming should be a “red flag” prompting medical evaluation to rule out an underlying risk of arrhythmia.
- . . . . .
These 2 cases highlight potentially life-threatening ventricular arrhythmias provoked by emotional surges while playing violent video games. We add this report to a recent correspondence discussing the association with ventricular arrhythmias and video games.7 This case report includes 2 distinct examples of documentation of the actual rhythm abnormality during electronic war games. This phenomenon occurred in both patients during periods of excitement, engagement, and/or frustration with the game.
Electronic video games are deliberatively designed to offer powerful affective experiences, and players typically go through a range of emotional responses that include frustration, anxiety, fear, excitement, and joy. In review of the literature, Wang and colleagues8 demonstrated a significant increase in heart rate and blood pressure among young boys playing video games; however, the magnitude was lower than observed during standard physical exercise. Other studies have demonstrated that the violent games have distinct effects on autonomic responses such as heart rate variability.9
We propose that only a very small group of children may possibly be at risk of arrhythmia during video gaming. These children are likely to have an underlying (previously known or unknown) cardiac arrhythmia disorder. Similar to exertional syncope, cardiac symptoms such as syncope or palpitations brought on by powerful emotions during video gaming should be a “red flag” prompting medical evaluation to rule out an underlying risk of arrhythmia. Th
e risk of a dangerous arrhythmia during competitive sports or swimming is well known in patients with inherited cardiac channelopathies such as long QT syndrome and CPVT.1 A similar mechanism may be occurring when children with arrhythmogenic conditions experience powerful emotions during particular phases of video gaming.
While the exact mechanism triggering the arrhythmia may be varied, given that both patients in this report had different conditions, 1 common part of the pathway is likely related to the sympathetic nervous system and adrenergic stimulation. Studies of the effects of intense emotion and mental stress, known triggers for ventricular arrhythmias, have demonstrated a shortening of the ventricular action potential.10
Recent studies have evaluated the safety of sports in treated patients with long QT syndrome and CPVT, and in patients with ICDs, and guidelines have followed suit, allowing for individualized shared decision-making.11, 12, 13, 14, 15 Key foundations to this approach are the clear cardiovascular and psychosocial benefits of exercise and sports, as well as the recommendation that safety plans be in place, including on-site AEDs.
In contrast to exercise and sports, violent video games do not provide cardiovascular benefits; furthermore, they are most often played in physical isolation, without the safety net of bystanders and AEDs. For these reasons, counseling of specific at-risk populations should include avoidance of participation in violent video games, as these games are an activity with risk and without health or psychosocial benefit.
reference link :https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7300337/
More information: Life-threatening cardiac arrhythmia and sudden death during electronic gaming: An international case series and systematic review, Heart Rhythm (2022). DOI: 10.1016/j.hrthm.2022.08.003