My Takeaways From ESC 2017: That Lovin’ Feeling? Barcelona Brings It Back

BARCELONA, Spain—There are two places your mind can go in the crush of a moving crowd. One is an upsweep of euphoria, the thrill of being part of something larger and more important than yourself. The other is a place of panic.

Sunday morning at the European Society of Cardiology (ESC) Congress 2017, I thought I’d allowed myself plenty of time to get to the opening late-breaking clinical trial session featuring the COMPASS and CANTOS trials. By the time I’d arrived at doors of the main arena, however, slim Spaniards in dark suits had their arms spread wide and were shaking their heads, waving the arriving throngs towards alternate entrances. This was an uncoordinated effort that ended up shunting eager attendees from one door, then another, so that we found ourselves swiftly pooling at the far-right entrance.

The crowd then slowed to a near halt, shuffling slowly into the packed auditorium. Despite the air of excitement for the trial results to come, I felt a mounting claustrophobia thumping in my chest. The previous evening, ESC organizers had warned us about just this sort of thing: a massive press of people congregating in Barcelona’s downtown for a “rally of unity” in the wake of the terrorist attacks. The city’s mayor herself had urged the people to “fill the streets to overflowing,” while the ESC, however subtly, offered advice to conference-goers wanting to keep out of the way.

Now here, funneling into the main arena, there must surely have been some badge-wearers recalling the niggling doubts they’d had about attending ESC 2017 after the events of the previous week. Snarled up, unexpectedly. Too many people, crammed in one place.

Part of me had hoped to attend Barcelona’s unity rally the night before, but it was the first busy day of the meeting and the TCTMD team didn’t make it out of the pressroom at Fira Gran Via until long after the rally had started. When we got to our Metro stop—one we’d been warned to avoid—the crowds had vanished. It was only when we set out for dinner an hour or two later that we saw people of all ages strolling home, trailing their children and placards. “I am not afraid,” the signs read. “No to Islamophobia,” said others. “The best answer is peace.”

The next day in ESC’s main arena there were no seats left by the time the crush of people got inside. Some elected to stay standing, shouldering into the few gaps that remained among along the rear wall of the auditorium. Others, like me, plunked themselves onto any remaining patches of carpet, knee-to-knee in companionable discomfort, joking about how badly someone had underestimated the turnout. The whispers and wisecracking died down when ESC President Jeroen Bax, MD, PhD (Leiden University Medical Center, the Netherlands), took the stage to open the session. This was why they’d come to Barcelona, despite the terrorist attacks on La Rambla less than a week earlier, despite the general unease that now attaches itself to the congregated, anywhere in the world.

New and Old

There is much more to be said and written about the two ‘blockbuster’ trials of the meeting. Will the dose of rivaroxaban (Xarelto; Bayer/Janssen) tested in COMPASS pave the way for non-vitamin K oral anticoagulant treatment in stable vascular disease, or will bleeding limit its use? Will canakinumab (Novartis), the fully human monoclonal antibody agent tested in CANTOS, become the next hot drug for reducing the risk of cardiovascular events in people with a previous MI and high-sensitivity C-reactive protein, or is cost its Achilles’ heel?

What struck me that Sunday, watching the results being delivered then discussed, was the infectious enthusiasm for the field, both onstage and off. For some, all these trials were academic medicine at its finest: a decade’s worth of work and tens of thousands of patients ultimately yielding a positive result. For others it’s the thrill that comes from learning new things, the prospect of something novel coming along that might actually help their patients.

Also striking at this year’s meeting was the amount of work being done, with equal passion, not on new drugs or strategies but on the old and entrenched.

DETO2X, for example, challenged the standard practice of giving supplemental oxygen therapy to patients with suspected acute MI without hypoxemia, and showed no impact on 1-year mortality as compared with patients receiving ambient air. VALIDATE-SWEDEHEART looked in a randomized fashion—for what may be the last time—at bivalirudin versus heparin in STEMI and NSTEMI patients, and found no advantage to the newer agent over heparin monotherapy for a composite endpoint of death from any cause, myocardial infarction, or major bleeding. The small PACIFY trial’s results raise the question of why all US cath labs—but few in Europe—depend so heavily on fentanyl, particularly since it seems to blunt the efficacy of antiplatelet drugs in STEMI.

Finally, CHANGE-DAPT took aim at the choice of antiplatelet therapy among patients with ACS and found that patients treated with ticagrelor after international guidelines went into effect did not fare better clinically and had more bleeding, as compared with those receiving clopidogrel prior to the change. The more potent drug may simply not be needed in an era of thin-strut drug-eluting stents, better medication compliance, and more radial PCI, presenter Clemens von Birgelen, MD, PhD (Thoraxcentrum Twente, Enschede, the Netherlands), said. “It makes sense to reconsider decisions taken 8 or 10 years ago when devices had more ischemic problems than now.”

Zest and Vigor

I’ve been to other major meetings—ESC 2016 was one of them—where the presenters seemed deflated, the trials underpowered, and the audience disappointed, jaded, and bored. This was not one of those meetings. Instead, Congress-goers seemed to descend this year with a zest and vigor matched only by the Catalan people themselves, surging into the streets and reclaiming their city: this is what we do, this is who we are.

I had anticipated sluggish security lines and bag checks at the Fira Gran Via convention center. Instead, the only long lines were for taxis, coffee, and the sessions themselves. In downtown Barcelona, I assumed I’d see the automatic weapons and chilly security I now take for granted on the streets of Paris and New York or the stiff upper lip of Londoners, keeping calm and carrying on.

Instead I sensed an effervescence that couldn’t be kept down. Warmth and joy. The beaches of Barceloneta and the streets of the Gothic Quarter were as busy as I’ve ever seen them: tourists gawking, families promenading, couples canoodling—everyone smoking like chimneys as if they’d live forever. (Spain, get your act together! But that’s a topic, perhaps, for another blog.) The only sobering sight was the makeshift memorial at the top of La Rambla, a shifting heap of notes, flowers, and toys ringed with candles attracting a somber crowd. But the messages, in many languages, appeared to be of ones of hope and solidarity.

I felt something similar in the corridors and meeting rooms of this year’s Congress: old friends and colleagues hailing one another and embracing, falling deep into passionate conversations over what they’d seen and learned. I saw laughter and joy. Of course we came was the undercurrent bobbing through ESC 2017. This is who we are. This is what we love.