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Game over: VTE is a risk in obese, sedentary teens



– It’s well known that airplane passengers, condemned to sit for endless hours in the claustrophobic cabins of the unfriendly skies, are at increased risk for venous thromboembolic events (VTEs). Less well documented, however, is the VTE risk encountered by overweight or obese teens who while their hours away playing video games.

“This is becoming a sedentary-type risk factor,” said Mira A. Kohorst, MD, from the division of pediatric hematology-oncology at the Mayo Clinic in Rochester, Minn.

Dr. Mira Kohorst

Dr. Mira Kohorst

“We think of counseling our patients about long flights, but I think, especially in our adolescent population, we need to talk to them about getting up and taking breaks during gaming, walking around, and stretching, because, when they get into gaming, they really hardly move at all because they are so engrossed in the game,” she said in an interview at the annual meeting of the American Society of Pediatric Hematology/Oncology.

Dr. Kohorst and her colleagues reported on a small but troubling trend of VTE episodes that they observed in teen boys over the last few years. They refer to obesity, sedentary lifestyle, and gaming as “the new thrombophilia cocktail in adolescent males.”

The reported incidence of pediatric VTE ranges from 0.7 to 4.9 per 100,000 person years, considerably lower than the 1 in 1000 estimated incidences reported in adults. But, thanks to the growing incidence of obesity in children, which more than doubled from 1980 to 2012 and quadrupled in teens age 12-19 years from 5% to 21%, youngsters appear to be catching up in the VTE department, the investigators reported.

“Given the direct mortality rate of 2% [that is] associated with VTE and risk for postthrombotic syndrome of 26%, it is important to understand underlying modifiable risk factors,” they wrote.

To do this, they retrospectively reviewed records of children who presented with VTE in their center.

All play, no exercise

The authors described three cases, including that of an 18-year old boy with a body mass index (BMI) of 37 kg/m2, putting him squarely in the obese category. This lad, who spent 12 or more hours a day playing video games and was sedentary at other times as well, presented with bilateral pulmonary emboli and an associated right lower lobe infarction. Testing for thrombophilia showed that he was heterozygous for factor V Leiden but did not have other coagulation abnormalities. He was started on enoxaparin (Lovenox) and then transitioned to apixaban (Eliquis) for a total of 6 months of thromboprophylaxis. He was counseled about modifying his lifestyle and did not have a recurrence after 14 months of follow-up.

A similarly sedentary 17-year old male with an even higher BMI (39 kg/m2) presented with bilateral basilar pulmonary emboli and infarctions in association with a left femoral deep vein thrombosis. This patients also had factor V Leiden heterozygosity and the May-Thurner (iliac vein compression) syndrome. He was treated for a total of 6 months with warfarin followed by rivaroxaban (Xarelto) and was counseled about lifestyle changes but was unable to lose weight. Eight months after completing therapy, he had a second extensive deep vein thrombosis, this time in his right leg, and was restarted on rivaroxaban.

The third patient, a morbidly obese (BMI 56 kg/m2) 13-year-old boy, presented with left lower lobe pulmonary embolism following 3 weeks of immobility caused by the Guillain-Barré syndrome. As in the other cases, he confessed to a sedentary lifestyle and a predilection for gaming. His father had previously developed a line-associated thrombus. The family declined thrombophilia testing. The patient received 3 months of enoxaparin. He has not been followed since discontinuing therapy.

Move it, kid!

The risk of VTE in adolescent boys, especially obese and extreme gamers who spend most of their waking hours in a chair staring at a screen, is similar to that for adolescent girls who use oral contraceptives, Dr. Kohorst and her colleagues said.

They recommend that clinicians ask adolescents about their gaming and TV-watching habits and encourage them to become more active to lower their risk for VTE.

The study was internally supported. Dr. Kohorst and colleagues reported no relevant disclosures.

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