Electronic gaming–associated life-threatening arrhythmias are an extremely rare occurrence, concluded a research team, which carried out the largest single-center study to date on this issue. The team suggested that while electronic gaming can have adverse health consequences, the threat of electronic gaming–triggered sudden death should not be used to try to curb time spent gaming. “Overall, although anecdotal e-gaming–associated cardiac events, including SCD, have been reported, the absolute risk is extremely low,” says the paper, written by authors led by Raquel Neves, MD, and Sahej Bains, BS, from the Mayo Clinic in Rochester, Minnesota. “Following proper diagnosis, risk stratification, and establishment of their treatment, a disease-mediated faint, seizure, or worse is very unlikely to occur during e-gaming, just as we have previously demonstrated for traditional athletes.” Retrospective review results Findings from the retrospective review published in the Aug. 15 issue of the Journal of the American College of Cardiology, reveal that out of the 3,370 patients with a genetic heart disease (GHD; mean age at first evaluation 27±19 years, 55% female), 1,079 (32%) had a cardiac event (CE) before diagnosis. In addition, five patients (0.5%) were found to have an electronic gaming–associated event (three catecholaminergic polymorphic ventricular tachycardia, one long QT syndrome (LQTS) and one premature ventricular contraction–triggered ventricular fibrillation). After diagnosis and treatment, 431 patients (13%) experienced ≥1 BCE during follow-up, of which one electronic gaming–associated BCE (0.2%) occurred in a patient with catecholamine-sensitive right outflow tract ventricular tachycardia. “Although the low level of risk associated with e-gaming has been shown in the present report, we emphasize the role of shared decision making and informed decision making regarding initiation or prohibition of e-gaming in patients with GHDs,” says the paper, which also published Monday online. “First, it may be prudent to obtain a history of e-gaming and eSports in patients with underlying GHDs during their evaluation and risk stratification. … Second, patients and providers should recognize that a syncopal event occurring in the setting of e-gaming must be scrutinized as diligently as a syncope occurring in a traditional sports setting in the evaluation for GHDs.” Dehydration and sleep deprivation The researchers went on to point out that patients should be reminded to not compound any potential risk stemming from e-gaming with additional factors such as dehydration and sleep deprivation. The team added that if BCEs occurred in temporal proximity to e-gaming, the risk/reward ratio must be re-evaluated. In an accompanying editorial comment, Shankar Baskar, MD, Richard J. Czosek, MD, and David S. Spar, MD, from the Cincinnati Children’s Hospital Medical Center, highlighted one limitation that focused on the retrospective nature of the study, which did not allow a “uniform and reliable assessment of electronic gaming history.” Further limitations of the study were the various confounders, which might have accompanied electronic gaming, such as caffeine intake, sleep deprivation, and dehydration, as well as the referral bias leading to a high-risk cohort. “If we now consider electronic gaming as a potential risk, what other activities need to be included?” the commentators asked The influence of the catecholaminergic drive Referring to the basis for CEs in susceptible patients, such as those with arrhythmic GHDs, a catecholaminergic drive seems to play a key role and can occur in many settings with activities of daily living or activities not considered to be competitive. “Ultimately these events although rare, 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,” the editorialists said. The commentators also mentioned ways to identify such activities before their resulting in a CE among susceptible patients. “An example might be a wearable or implantable monitor that could warn patients of a higher catecholaminergic state,” they suggested. “Regarding those without a prior diagnosis, future policies and research might need to consider assigning a red flag to syncope occurring in a catecholaminergic state rather than just sports.” Study methodology From July 2000 to November 2022, 4,798 patients were evaluated in Mayo Clinic’s Windland Smith Rice Genetic Heart Rhythm Clinic. Among 3,370 patients (70%) with a diagnosis of a GHD, the mean age at their first Mayo Clinic evaluation was 27±9 years, and 1,861 (55%) were female. The three most common diagnoses among the 3,370 patients were LQTS in 1,764 (52%), CPVT in 232 (7%), and hypertrophic cardiomyopathy in 194 patients (6%). The term “cardiac event” was used to define events occurring before diagnosis whereas breakthrough cardiac event was used for events occurring after diagnosis. Electronic medical records were reviewed for patient demographics, clinical characteristics, genotype and circumstances surrounding their cardiac event. CE was defined as arrhythmic syncope/seizure, appropriate implantable cardioverter-defibrillator (ICD) therapy, sudden cardiac arrest (SCA) or sudden cardiac death (SCD). Sources: Neves R, Bains S, Bos JM, et al. Fatal Cardiac Arrhythmias During Electronic Gaming in Patients With Genetically Mediated Heart Diseases. J Am Coll Cardiol. 2023;82:603–611. Baskar S, Czosek RJ, Spar DS. A Look Beyond the Sports Field: A Paradigm of Shared Decision Making in Everyday Life. J Am Coll Cardiol. 2023;82: 612-614. Image Credit: Zamrznuti tonovi – stock.adobe.com