Using the mentioned method, we found 24 relevant cases up until the end of 2021, and numbered them in chronologic order. We did not anonymize the victims since their names are publicly available. Cases are summarized in Table 1, highlighting specific characteristics, discussed later. More detailed descriptions of the cases are available in the Appendix.
An isolated case was reported in the early 1980’s, but the cases of real interest started after 2002, with 1 or 2 cases every year or two years, but without trend for remarkably increasing incidence.
Table 1.: Summary of cases
Demographic and geographic characteristics
Only one of the reported victims was female (No. 8), but we do not know about the length and intensity of her gaming.
Internet addiction among females usually involves addiction to social media rather than gaming - IGD is seven times higher among male than female adolescents . It seems that deaths were connected to action-rich games (see below), which are less popular among females. Competitiveness in games is more common among males, which may bind them for a long period to the game without pausing.
The victims were mostly adolescents or young adults (age ranging from 11 to 40 years). The first few victims died in their twenties; this was the age group that primarily got acquainted with computer games, and in whom IGD became an emerging problem. In the following years, age of victims broadened. The former teens and twenties aged to thirties. Further spread of computers, internet and games reached the very young age group, as well – nowadays kids often start to play video games before learning to read, and get their game-able smartphone before 10 .
More than half of the cases originate from Southeast Asia (Taiwan, China, South Korea, Thailand) and most of them (12 cases) happened in internet cafes. It is not that surprising according to the popularity of these places . Buying gaming hours are cheap, and are far more economical alternative for young players than paying for an own PC, broadband internet connection, electricity and the games themselves . Moreover, internet cafes provide cheap food and drinks, some even private rooms with beds to sleep or to shower. With 0-24 opening hours a customer may not even need to move out for days. Without supervision, young people can get away from their parents, escape reality, and get lost in the game undisturbed without thinking about the pressures of school and work . On the other hand, in the cases from the western region the gaming event happened at home, as internet cafés never had such high popularity, due to the expansion of home-based e-mail and internet access points . In the recent years rapid spread of smartphones has been restructuring Internet access and gaming, as well, and the first gaming deaths linked to smartphones also appeared.
Incidence of death by gaming
Using the above mentioned data, we tried to give a very rough estimation about the incidence of gaming related death. Number of internet users is growing, being around 2 billion (28% of 7 billion people in 2010) and 3 billion (41% of 7.38 billion people in 2015) [9,S53]. Risk population seems to be males from 15 to 40 years, so about 360-540 million; we used 450 million for further calculation.
Using the 2014 Asian data, the prevalence of IGD among adolescents was estimated to be 5%, but since most of them were males, we used 10% for males. The population at risk (adolescent males with IGD) may be around 45 million. This means a roughly 1 death per 2 million gamers over about 15 years course, or 1 per 30 million yearly. Considering only the most avid gamers the incidence is probably higher.
Games involved in death cases
In most cases the name (or the category) of the game the victim had been playing was reported. Detailed description of these categories is provided in the Appendix. The common feature of these games is that they all need strong, strenuous mental concentration. The gamer may lock out the disturbing outside world, lose track of the passing time, and dimly notice hunger, thirst, tiredness or discomfort, which may lead to the adverse consequences. No one was reported to die while playing a sandbox game (like The Sims, Minecraft) [S59], where player use creativity instead of action, or an adventure game [S60], which involves exploring and playing along a storyline (sprinkled with action and dexterity elements) in an enjoyably slow pace instead of the aforementioned rush. The games played were definitely or presumably multiplayer games, where the competitive factor or adaptation to the other players enforces the gamer into a faster pace and prevents him from stopping, contrary to single-player mode, where one can do it in his own pace.
Cause of death
Ten victims were reported to have co-morbidities or risk factors: extreme obesity (No. 4), obesity (No. 8 and 23), asthma (No. 9), previous heart attack (No. 10) or heart problem (No. 21), high blood pressure (No. 21) liver disease/gallstones (No. 14), broken leg (No. 17), smoking (No. 2, 14 and 18), in the other cases such risk factors were not known.
Five sudden deaths were caused by pulmonary embolism (PE). A critically large embolus can lead to hemodynamic collapse, shock and death, which happens in about 10% of the cases . Autopsy can unequivocally prove or rule out the embolism, but preceding symptoms (sudden onset, stabbing chest pain, dyspnea, coughing up blood, swollen leg) may suggest the diagnosis, as well. Prolonged immobilization, bedrest or long sitting and dehydration are well- known risk factors for deep venous thrombosis (DVT) in the lower limb. “Economy class syndrome” refers to DVT of aircraft passengers, where prolonged sitting cause venous stasis, may damage the endothelium of the veins, while dehydration due to dry atmosphere or drinking less, further increase risk of thrombus formation. Aforementioned gamers were similarly sitting long and moving little. Focused on the game they may be less aware of being stiff and sore, or thirsty. Obesity and smoking are further relevant risk factors. After thrombus formation, PE may strike later or in waves, like in case of Chris Staniforth (No. 8), who mentioned ‘strange feeling’ in his chest the previous night, and died at the JobCentre next day. Besides 22 days of sedentary gaming, Rustam (No. 17) had a broken leg, which increases risk of DVT over 10-fold on its own . Besides the extent of embolism, survival is determined by the ability to compensate for the increased resistance of pulmonary circulation, requiring good right ventricular function with adequate preload and autonomic regulation. Young subjects are expected to have better chances than elder ones. Autonomic dysfunction (explained later) and hypovolemia due to dehydration may have contributed to the death of the gamers.
In one case (No. 22) stroke in another (No. 24) cerebral haemorrhage was reported as cause of death. Stroke was not further specified. It might have been ischemic stroke, which often causes disability but rarely sudden death, and is very hard to be explained at this age. It more probably could have been haemorrhagic stroke or subarachnoid haemorrhage. Haemorrhagic stroke in young adults can be caused by hypertension, vascular malformation, drug abuse, venous sinus thrombosis, hematologic conditions. According to the bleeding location and size, it may lead to herniation, coma or death. Subarachnoid haemorrhage is due to the rupture of saccular aneurysms in more than half of all cases. 25% of these patients die within 24 hours of the event; many die before they reach the hospital. Hypertension or acute elevation in blood pressure, smoking are risk factors for aneurysmal haemorrhage .
In many cases (No. 1,3,6,9,10,15,20,21,23) ‘heart failure’, ‘heart attack’ or ‘cardiac arrest’ was named as cause of death, though the terms may not have been medically properly used. In other cases, definite cause of death was not even specified or speculations (like “overwork and obesity”, “fatigue”) were reported. Sudden cardiac death (SCD) developing such rapidly almost always happen due to onset of malignant ventricular arrhythmia (ventricular fibrillation, extremely fast ventricular tachycardia) or sudden severe dysfunction of the sinus or AV node without escape rhythm. Other possible specific causes (like extreme extent myocardial infarction and loss of pump function or aortic dissection leading to rapid bleeding or pericardiac tamponade) are improbable and could be easily identified during autopsy. Arrhythmia on the other hand often lacks obvious structural background. However, autopsy results or background medical information were available only in few cases, mostly the cases from the Western countries. For the Asian cases these were either not performed, or the international news agencies were not interested in writing follow-up articles. In many cases excitement, fatigue, physical exhaustion, sleep deprivation, dehydration, lack of movement, were named as contributing factors to the cardiac death.
Some cases seem out of the pattern. Tim Eves (No. 6) was playing on Wii Fit, where player actually moves and jogs, turning gaming into a sport, a mild to vigorous aerobic training. Circumstances did not suggest anything extraordinary either. His death is rather sport-related than game-related. Anna-Lee Kehoe’s (No. 9) symptoms did not resemble an asthma attack, even complete airway obstruction would result in a longer agony. Symptoms rather suggest massive pulmonary embolism, and the source did not mention if examinations or autopsy was performed to rule it out. On the other hand, thrombosis at such young age is unlikely without the presence of thrombophilia. Though no obvious provoking factors were mentioned, arrhythmia-related death (heart attack) is possible in the presence of underlying disease (like arrhythmogenic right ventricular cardiomyopathy or channelopathy). Similarly, in Burkowski’s case (No. 1) the half hour gaming session must have been no overexertion or overly stressful for the experienced player (who set up to top-10-scores). The scar on his heart, that probably was involved the lethal arrhythmia, is of unknown origin: cardiomyopathy, peri/myocarditis, mechanical injury or an unlikely myocardial infarction? He probably could have died due to any other physiological stressors or excitement, as well. Similarly, in other cases (No. 20, 21, 24), though the victims were gaming addicts, no extremity was reported about the last gaming session. If there is a very low chance of death during a gaming session, there is obviously a higher cumulative chance for ones who repeatedly do it.
Bogdan Akh’s (No. 19.) death is not connected to uncontrolled gaming binge, but to a scheduled training for a competition, and we may consider it the first eSport related death (see below). Extreme exhaustion is unlikely, it was probably avoided in favour of the best performance on the competition. Strangely, death occurred not around the training or the competition, but after them, during rest, when all stress subsided. Could this change in balance be the trigger, or were there other possible factors, like a celebration after the competition?
Sleep deprivation and death
In 18 cases the gaming session before death was extremely long (around a day or even several days) with minimal rest, which results in acute sleep deprivation, or the victim was repeatedly playing quite long sessions, which suggests chronic sleep deficiency.
Sleep is a natural relaxing state for regeneration . Uncomfortable effects of acute or chronic sleep deprivation (SD) are experienced by almost everyone; impaired concentration, reduced mental and physical performance, mood alterations, irritability, to mention some. They may indirectly lead to fatal consequence, like falling asleep and causing a traffic accident. It is another question though if or when can SD itself trigger or contribute to a biological shock resulting in death, like in the aforementioned gamers. In an animal model of acute SD, all rats died within 2-6 weeks of continuous or paradoxical SD . The animal lost weight despite increased food intake, showed altered thermoregulation, but no obvious changes in brain morphology or function could be demonstrated.
Experimental data of such drastic SD in human is not available. In a study, subjects after a night with sleep dept (still 1.7 hours sleep on average) showed increase of the QT interval and QT dispersion (still within the normal range), which may make more susceptible to lethal ventricular arrhythmias . A case report demonstrated spontaneous coronary dissection and myocardial infarction after 72 hours SD due to overtime work .
Several longitudinal human studies demonstrated a U-shaped association between sleep duration and all-cause mortality, optimal amount being around 7 hours sleep per day, with increased mortality of both short and long sleepers [17,18,19,20,21]. Besides direct effect of SD, short sleep may also contribute to development physiological and social outcomes that may lead to increased mortality; e.g. cardiovascular disease, stroke, dyslipidemia, diabetes, hypertension, obesity, cancer, presence or development of stress, altered inflammatory cytokine levels and impaired immune response [22,23,24]. Exact sleep habits of the gamers are not known, but it is presumable that the ones who were indicated as gaming addicts, and were doing regular several-day-long gaming binges or over 10-hour daily gaming sessions, were also taking away time from sleeping in favour of gaming, and are on the short-sleeper arm of the curve. The above results are also based on mainly middle-aged or elder subjects, and applying them on the mostly young gamers is questionable. On the other hand, chronic short-sleeping may have already done subclinical damage in these individuals, making them more susceptible to an acute event.
Sport and sudden cardiac death
Eventual, unexpected, sudden cardiac death (SCD) cases are reported in another field, as well: sports and athletes. We tried to apply such experiences to our population. Public and medical attention is high for such events, the cases and causes are usually thoroughly investigated. Widespread registers offer more reliable data in contrast to the cases of video gamers. Due to inconsistencies of definitions incidence widely vary between 1 in 3000 and 1 in million athlete per year . Higher incidence was found among males (3-5 times) and blacks (3 times), . Deaths occur most commonly in team sports, which have the highest levels of participation . In a study, media database reports identified 70% of the total SCD cases, suggesting the high media attention of such unexpected death on young ones . In many cases structural abnormalities (hypertrophic cardiomyopathy or idiopathic left ventricular hypertrophy, dilated and restrictive cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, congenital coronary anomalies, aortic rupture due to Marfan syndrome, myocarditis, valvular disease, commotio cordis) were present, but individuals with morphologically normal hearts were common, as well, referred to as sudden arrhythmic death syndrome (SADS). In some of them primary electrical disorders or channelopathies (like Brugada syndrome, Wolff–Parkinson–White syndrome, long QT syndromes) could be identified, but about 30% remained unexplained.
Outstanding performance attracts audience in gaming, as well, which up today turned into a rapidly growing industry, eSport, with over 1 billion audience , and with gamers doing it as a full-time profession. Average eSport player practices between 5.5 and up to 10 hours a day prior to competitions. 15% reported 3 hours or more of sitting and playing without standing to take a break. This sitting for hours staring the monitor with several hundred clicks and keypresses per minute results in chronic overuse (and sometimes career-ending) injuries (eye fatigue, neck or back pain, wrist and hand pain), but one case of deep venous thrombosis was also reported . As far as we know, up until today no case of death among eSport athletes linked to gaming was officially reported. On the other hand, eSport community is far smaller, and exists for a shorter time than the general gamer and IGD population, and the lower numbers may have just not produced a death case.
Stress and cardiac death
Death of Chen Rong-Yu (No. 10), was a well investigated, still unexplained case, about which we have more detailed information from an interview with his physician, Dr. Ta-Chen Su in the book Death by video game . Rong-Yu had had a heart attack 3 months before. Extensive examinations (including ECG, echocardiography, 24-hour ECG, coronary angiography, cardiac electrophysiology study) did not show underlying abnormalities. Cardioverter defibrillator implantation was suggested which Rong-Yu refused. Dr. Su provided further hypotheses about his death, elaborated below.
Most organs are regulated by the sympathetic and parasympathetic nervous system, their balance and reaction to stimuli adapt the organ’s function (like blood pressure, heart rate, respiration, metabolism) to the actual needs. Prolonged or extreme stimuli may upset this balance, and result in so called acute autonomic dysfunction causing functional and sometimes morphological organ abnormalities, which can rarely lead to fatal consequences. Such manifestations in the heart can be various arrhythmias, myocardial infarction, takotsubo cardiomyopathy and sudden death .
Sleep deprivation is accompanied by a rise in sympathetic tone to maintain arousal and counteract parasympathetic impulses driving the body to a relaxing, regenerative state , ultimately resulting in a mentioned imbalance and autonomic disfunction. It can also be a part or trigger of acute or chronic stress reaction.
Gaming itself produce stress, according to cardiologist Robert S. Eliot, (M.D. at the University of Nebraska Medical Center), who used a video game (Pong) to replicate stressful situations in more than 1000 patients. Heart rate increases of 60 beats per minute and blood pressures as high as 220 was often observed within one minute of starting a computer game, without the patients being aware of that . Similarly, increase in heart rate and blood pressure was observed in eSport athletes, as well [32,33], although such high alteration was not pronounced. Acute elevation of blood pressure can trigger lethal arrhythmia in some cases . Present of stress during eSport activity can be demonstrated by the elevation of stress hormones , just like during physical sports .
Acute emotional distress (especially anger-like stress) may provoke ventricular arrhythmia, as well as acute myocardial infarction [37,38], but stress due to assault  or natural disasters are reported as triggers for SCD, as well . 20 to 40% of sudden cardiac deaths may be precipitated by acute emotional stressors. A gamer may feel strong anxiety in an unfamiliar situation, panic in a high risk-high stake scenario, frustration when failing a challenge and lose progression or rage when repeatedly losing or getting “owned”.
Even if the game is not especially stressful, extremely long gaming session could be compared to overtime at working, leading to exhaustion. In Japan several hundred cases were reported where people have died while repeatedly working overtime (termed as karoshi: death by overwork) [41,42].
Dr. Su mentioned air pollution as another possible factor: Taiwan’s air relative humidity usually remains at 60-90%, that help fungi, bacteria and dust mites to flourish in a confined space. Taiwanese internet cafés were typically crowded, smoking regulation was more liberal at that time, poor ventilation and air conditioning may cooled but not improved the quality of air . Air-pollution index in internet cafés often exceeded safe levels. Severe air pollution was shown to trigger coagulation and thrombosis, increase heart rate and reduce heart rate variability, cause endothelial dysfunction, arterial vasoconstriction, apoptosis, and hypertension. In chronic exposures these contribute to the progression of atherosclerosis, but even acute exposures can lead to autonomic nervous system imbalance, plaque instability, and trigger acute cardiovascular events (myocardial ischemia and infarction, stroke, heart failure, arrhythmias, and sudden death) . Air pollution may contribute to acute autonomic dysfunction, as well, just like sleep deprivation, acute and chronic, emotional or physical stress, which may explain the sudden unexpected/unexplained death of gamers.