eSports, exergames, and eAthletes: opportunities and challenges for preventive cardiology on a global scale

The history of electronic sport (eSport, Esport, or e-sport) dates to at least the 1970–80s when video game consoles were introduced to the mass market, with subsequent development and organization into large-scale multiplayer competitions involving professional contestants and online spectators worldwide. By 2017, eSport has become a major industry and global spectator sport attracting no fewer than 385 million viewers worldwide with a market worth US$2.89 billion (https://britishesports.org). Continual growth in eSports has seen the establishment and organization of companies and institutions into intervarsity academies, professional leagues, and associations (e.g. World Esports Association, eSport-Bund Deutschland e.V., and Shenzhen Esports Association). Through evolution and generational progression from Sega, Atari, Nintendo, PlayStation, Wii Fit to Xbox Fitness and other gaming platforms, ‘active video games’ and competitive eSports are no longer considered game plays associated with sedentary, inactive lifestyle.1–4 As an example, fitness games (exergames) have been explored over the last decade as an adjunctive tool to increase motivation for patients undergoing cardiac rehabilitation.5 Exergaming in patients with heart failure can enhance physical activity and motivation while lowering barriers to exercise. On the other hand, professional eSport can be fiercely competitive and incorporate virtual reality, highly imaginative and experiential challenges that significantly increase metabolic rate, energy expenditure (EE), and cardiopulmonary function (e.g. increased VO2 and VCO2).4 To date, the competitive conditions and standards of eSports remain poorly understood and defined.4 So, is eSport a real sport? Bailey et al.1 studied 39 children (age 11.5 ± 2.0 years) and found that among the 6 forms of exergames played under leisurely condition, EE was elevated to moderate-to-vigorous intensity, similar to treadmill walking in the range of 5–6 metabolic equivalents (METs), with no significant difference between game genres. Melmer et al.3 studied 20 sedentary adults aged 18–55 years who were otherwise healthy and found that regular exergaming 3 times weekly with exertion to ≥80% of maximum heart rate over 6 weeks led to improvement in VO2max and decreased heart rate, blood pressure, and LDL levels. Examining FIFA 21 (n = 14) vs. League of Legends (n = 13) players (age 23.3 ± 2.8 years) under standardized conditions, Ketelhut et al.2 compared cardiovascular and metabolic variables [e.g. heart rate, blood pressure, heart rate variability (HRV), arterial stiffness, and EE] and found no significant difference between game genres and platform. Another study showed that expert eAthletes (i.e. those ranked within top 10% of their game) experienced increased physiological demands and significant changes to metabolic rate, EE, and cardiovascular function during gameplay.4 The exercise physiology and cardiovascular function of eAthletes, particularly at the elite level, remain poorly understood and warrant further detailed studies. On the clinical ground, eAthletes and professional gamers tend to have a high burden of symptoms, acquired injuries, and disorders that are proportional to game time. Emerging health problems include internet gaming disorder characterized by adverse changes in HRV, parasympathetic inhibition, and emotional problems.6 Accumulating evidence suggests that active video games can increase not only EE but also food intake. A myriad of symptoms, health problems, physiological derangements, and cardiovascular and metabolic disorders are increasingly recognized in eSport gamers.6 Although arrhythmic events directly attributable to video games are very rare, a 2-decade retrospective review of genetic heart disease cases from Mayo Clinic showed that 6 individuals (0.18%) among a cohort of 3370 patients had experienced life-threatening cardiac arrhythmias during electronic gaming.7 Four patients (ages 11–18 years at the time of diagnosis, 3 male and 1 female) had ventricular arrhythmias attributable to genetic susceptibility related to catecholamine sensitivity (2 nonsynonymous pathogenic variants in ryanodine receptor 2 (RYR2), 1 variant in calsequestrin-2 (CASQ2), and 1 undefined), and in the remaining 2, one had long QT syndrome type 1 (attributable to KCNQ1-P.Arg192Cysfs*91) and the other had premature ventricular complex–triggered ventricular fibrillation associated with a variant of uncertain significance in the lamin A/C gene (LMNA).7 Considering the large numbers of competitors and participants in eSports, it is foreseeable that the conglomerate of genetic heart diseases [e.g. hypertrophic cardiomyopathy (1:500), long QT syndrome (1:2000), and catecholaminergic polymorphic ventricular tachycardia (1:10 000)] and their potential life-threatening manifestations (e.g. ventricular arrhythmias and sudden cardiac arrest) can unpredictably strike the genetically susceptible individuals as in traditional competitive sports. The implications for public health management targeting actionable cardiovascular disease associated with video gameplay and exergaming can be profound, particularly for high-level eSport (Figure 1). Although eSport is not (yet) featured in Olympic competition, the International Olympic Committee regards electronic games simulating sports to have great potential for consideration in future Olympics. Rossoni et al.6 made a strong argument in an updated review on eSport from the perspective of sports medicine and advocated health management pathways including adapted pre-participation screening, disease prevention, and injuries management for eAthletes as for all other athletes. Prospective longitudinal observational studies are needed to determine if this approach is evidence-based and feasible for the competitive eAthlete population. Global distribution of video game players displayed according to continent or region. Histogram depicts actual number of active eSports competition players or eAthletes sorted by country and continent or region. Data source: Statista (2023). Pre-participation screening can begin with history taking using a structured questionnaire that incorporates focused elements, followed by physical examination.6,8 Although the limitations of structured questionnaire (very low sensitivity of 18.8% and moderate specificity of 68% for the American Heart Association 14-point evaluation) are recognized,9 they represent a cost-effective approach to mass screening. Recent evidence supports the increased use of electrocardiography (ECG) interpreted according to the 2017 International Criteria10 in pre-participation cardiovascular screening for competitive athletes, given their additive diagnostic yield and importance demonstrated in many published studies. We foresee that a tailored approach to the individual eAthlete with selective implementation of ECG in case of suspected arrhythmogenic genetic or structural substrate may be considered. However, what is certain based on current evidence in the literature is that competitive eSports can be physically and emotionally taxing, demand cardiorespiratory fitness and physical endurance, and potentially induce life-threatening arrhythmia in a very small group of susceptible individuals with genetic heart disease.7 E.F. is immensely grateful to the late Prof. Sir David Todd, CBE, JP, MD, FRCP, FRCPath for the support in establishing the Gerald Choa Cardiac Research Centre at CUHK. None declared. No new data were generated or analysed in support of this research.