It's not just sports, case series shows While sports can be risky for kids with arrhythmogenic cardiac conditions, researchers are now reporting four cases in which video games triggered syncope from ventricular tachycardia or fibrillation. In each case, it was a boy (ages 10 to 15) playing an electronic war game at home, reported Claire M. Lawley, MBBS, of the University of Sydney, and colleagues from Australia and New Zealand in a letter in the New England Journal of Medicine. "Current international guidelines recommend avoidance of strenuous activity and competitive sports for young people with potentially arrhythmogenic cardiac conditions," they noted. "Children excluded from sports activities may seek alternative sources of entertainment and excitement, including electronic gaming, yet their safety in this context is not established." The series puts gaming on the radar as a risk, which is "eye opening," commented Angelo Biviano, MD, MPH, director of the cardiac electrophysiology lab at NewYork-Presbyterian/Columbia University Medical Center in New York City. How common such cases are isn't clear, particularly because there's less of a chance for bystanders to witness what is often solo game-play than with active sports, he noted. The first patient in the case series was age 10 when he passed out after winning his video game. Although he quickly regained consciousness, he later went into cardiac arrest from ventricular fibrillation at school and was diagnosed with catecholaminergic polymorphic ventricular tachycardia. IV adrenaline challenge identified polymorphic ventricular ectopy, and genetic testing pointed to a "likely pathogenic" genetic variant. "Mental stress and heightened emotion have been shown to shorten the ventricular action potential and are known triggers for cardiac arrhythmia, particularly in long-QT syndrome," the researchers noted. "Increases in sympathetic activation and adrenergic stimulation, mimicked here by the adrenaline challenge in Patient 1, are proposed as the mechanism for this phenomenon." The second case, a 15-year-old born with transposition of the great arteries with ventricular septal defect, likewise became presyncopal at the point of winning an electronic war game. He was diagnosed with rapid monomorphic ventricular tachycardia and cardioverted in the emergency department. Despite starting on metoprolol and getting an implantable cardioverter-defibrillator (ICD), he had a second episode when about to win the same video game 2 months later, which the ICD cardioverted. In the third case, an 11-year-old lost consciousness "after having palpitations while animatedly playing an electronic war game with a friend," although they couldn't recall where in the game they were at the time. He was diagnosed with long-QT syndrome (interval corrected for heart rate 570 msec), as were several family members. For people known to have potentially arrhythmogenic cardiac conditions, this small case series may be enough to make some recommendation, Biviano suggested. "In that small minority of patients who have potential abnormalities like this, then counseling about not only strenuous activity and competitive sports, but also electronic gaming, should be considered," he said. The researchers disclosed no relevant relationships with industry. Biviano disclosed a relevant relationship with Boston Scientific.