Cor Vasa 2026, 68(1):43-50

Predictors and Outcomes of No-reflow among Acute ST-Segment Elevation Myocardial Infarction Patients

Beshoy Yacoub, Amir Anwer Shaker, Sameh El-Kaffas, Mohammed El Ramly, Mohamed A. Abdelwahab

Department of Cardiovascular Medicine, Kasralainy Hospital, Cairo University, Cairo, Egypt

Background: The no-reflow phenomenon (NRP) can occur in up to 40% of patients after primary percutaneous coronary intervention (PPCI) for acute ST-segment elevation myocardial infarction (STEMI). NRP significantly diminishes the benefits of reperfusion therapy, leading to increased infarct size and poorer outcomes. Although the exact pathophysiology of non-reperfusion injury (NRP) is not fully understood, various factors may contribute to it through different mechanisms.

Aim: In this study, we aim to investigate clinical and interventional predictors of no-reflow and their impact on in-hospital outcomes among a cohort of acute STEMI patients presenting to a tertiary care center in Egypt.

Methods: A total of 1,015 patients were admitted to Kasralainy Hospital with high-risk acute coronary syndrome, including 502 with STEMI and 513 with NSTEMI. This prospective study included 337 patients who had chest pain for over 20 minutes in the 48 hours before admission, met the criteria for acute STEMI, and underwent PPCI. These patients were divided into two groups based on the angiography findings: the no-reflow group (n = 72) and the reflow group (n = 265).

Results: Both groups were similar in age and gender, with average ages of 56 ± 10 years in the no-reflow group and 55 ± 10 years in the reflow group. Males were predominant, and the reflow group had a higher rate of diabetes mellitus (p = 0.034). Most patients in both groups had anterior myocardial infarction (MI) (61% in no-reflow vs. 56% in reflow, p = 0.1). The no-reflow group had a longer median pre-hospital delay (6.5 hours) compared to the reflow group (5.0 hours), with 61% of no-reflow patients presenting late (chest pain > 6 hours) versus 45.7% in the reflow group (p <0.024). Most patients received loading doses of dual antiplatelet therapy (DAPT), predominantly clopidogrel (82% vs. 18% for ticagrelor), with no significant differences between groups. The median door-to-wire crossing time was longer in the no-reflow group (110 vs. 90 minutes; p = 0.007). Only pre-hospital delay (> 6 hours) (p = 0.024) and door-to-wire crossing time (p = 0.007) were associated with no-reflow, with the latter being an independent predictor (p = 0.009). The no-reflow group experienced more in-hospital complications, with major adverse cardiovascular events occurring more frequently compared to the reflow group (24% vs. 12.4%, p = 0.024). Furthermore, they had lower post-catheterization ejection fractions (median 42% vs. 50%; p <0.0001).

Conclusion: Despite advances in managing ST-segment elevation myocardial infarction, the no-reflow incidence after primary PCI remains significant, linked to higher mortality and poor prognosis. This study found that prolonged pre-hospital delay (over 6 hours) and longer door-to-wire crossing times are independent predictors of no-reflow. Efforts should focus on reducing pre-hospital delays and optimizing in-hospital pathways to minimize door-to-wire times.

Keywords: No-reflow phenomenon, Primary PCI, STEMI

Received: June 29, 2025; Revised: July 31, 2025; Accepted: August 4, 2025; Prepublished online: June 2, 2012; Published: March 15, 2026  Show citation