Correlates of the “No-Reflow” or “Slow-Flow” Phenomenon in Patients Undergoing Primary Percutaneous Coronary Intervention

  • Mohammad Alidoosti Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
  • Reza Lotfi Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
  • Masoumeh Lotfi-Tokaldany Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
  • Ebrahim Nematipour Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
  • Mojtaba Salarifar Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
  • Hamidreza Poorhosseini Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
  • Arash Jalali Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
Keywords: Myocardial infarction, Percutaneous coronary intervention, No-reflow phenomenon


Background: Despite recent advances in interventional equipment and techniques, the angiographic no-reflow phenomenon occurs in a considerable number of patients undergoing primary percutaneous coronary intervention (PCI). We investigated the clinical, angiographic, preprocedural, and procedural characteristics associated with the no-reflow phenomenon among patients undergoing primary PCI. Methods: Between March 2008 and April 2013, 530 patients (78.5% male, mean age=58.11±12.39 y) with ST-segment-elevation myocardial-infarction who underwent primary PCI were categorized in 2 groups according to their postprocedural thrombolysis-in-myocardial infarction (TIMI) flow grades:  those with a maximum score of 2 (the no-reflow or slow-flow group) and the ones with a score of 3 (the reflow group). A multivariable logistic regression model was used to find the multiple correlates of the no-reflow phenomenon after PCI. Results: There were 166 (31.3%) patients in the no-reflow group and 364 (68.7%) in the reflow group. The no-reflow patients were older and had significantly longer target lesion lengths, higher SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) scores, higher infarct-related artery SYNTAX scores, more thrombus burden, and a higher frequency of initial TIMI flow grades of 2 or lower. Our multivariable logistic regression analysis demonstrated that older age, higher numbers of Q waves, not using statin, longer target lesion lengths, higher thrombus grades, and higher infarct-related artery SYNTAX scores remained the independent correlates of increased no-reflow rates after primary PCI (area under the ROC curve=0.784,  95% CI: 0.742–0.826; P<0.001). Conclusion: Clinical, angiographic, and procedural features of patients undergoing primary PCI may be correlated with the occurrence of the no-reflow phenomenon. The thrombus grade and the infarct-related artery SYNTAX score could be among these factors.


Brodie BR, Stuckey TD, Hansen C, Muncy D. Benefit of coronary reperfusion before intervention on outcomes after primary angioplasty for acute myocardial infarction. Am J Cardiol 2000;85:13-18.

Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361:13-20.

Stone GW, Cox D, Garcia E, Brodie BR, Morice MC, Griffin J, Mattos L, Lansky AJ, O'Neill WW, Grines CL. Normal flow (TIMI-3) before mechanical reperfusion therapy is an independent determinant of survival in acute myocardial infarction: analysis from the primary angioplasty in myocardial infarction trials. Circulation 2001;104:636-641.

Ramjane K, Han L, Jin C. The diagnosis and treatment of the no-reflow phenomenon in patients with myocardial infarction undergoing percutaneous coronary intervention. Exp Clin Cardiol 2008;13:121-128.

Chan W, Stub D, Clark DJ, Ajani AE, Andrianopoulos N, Brennan AL, New G, Black A, Shaw JA, Reid CM, Dart AM, Duffy SJ. Usefulness of transient and persistent no reflow to predict adverse clinical outcomes following percutaneous coronary intervention. Am J Cardiol 2012;109:478-485.

Magro M, Nauta ST, Simsek C, Boersma E, van der Heide E, Regar E, van Domburg RT, Zijlstra F, Serruys PW, van Geuns RJ. Usefulness of the SYNTAX score to predict "no reflow" in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Am J Cardiol 2012;109:601-606.

Cakici M, Cetin M, Balli M, Akturk E, Dogan A, Oylumlu M, Abus S, Yildiz E, Sungur A, Celiker M. Predictors of thrombus burden and no-reflow of infarct-related artery in patients with ST-segment elevation myocardial infarction: importance of platelet indices. Blood Coagul Fibrinolysis 2014;25:709-715.

Chen Y, Wang C, Yang X, Wang L, Sun Z, Liu H, Chen L. Independent no-reflow predictors in female patients with ST-elevation acute myocardial infarction treated with primary percutaneous coronary intervention. Heart Vessels 2012;27:243-249.

Şahin DY, Gür M, Elbasan Z, Kuloğlu O, Şeker T, Kivrak A, Tanboğa İH, Gözübüyük G, Kirim S, Çayli M. SYNTAX score is a predictor of angiographic no-reflow in patients with ST-elevation myocardial infarction treated with a primary percutaneous coronary intervention. Coron Artery Dis 2013;24:148-153.

Iwakura K, Ito H, Kawano S, Shintani Y, Yamamoto K, Kato A, Ikushima M, Tanaka K, Kitakaze M, Hori M, Higashino Y, Fujii K. Predictive factors for development of the no-reflow phenomenon in patients with reperfused anterior wall acute myocardial infarction. J Am Coll Cardiol 2001;38:472-477.

Li XD, Yang YJ, Hao YC, Yang Y, Zhao JL, Dou KF, Gu DF. Effect of pre-procedural statin therapy on myocardial no-reflow following percutaneous coronary intervention: a meta analysis. Chin Med J (Engl) 2013;126:1755-1760.

Hong YJ, Jeong MH, Choi YH, Ko JS, Lee MG, Kang WY, Lee SE, Kim SH, Park KH, Sim DS, Yoon NS, Youn HJ, Kim KH, Park HW, Kim JH, Ahn Y, Cho JG, Park JC, Kang JC. Predictors of no-reflow after percutaneous coronary intervention for culprit lesion with plaque rupture in infarct-related artery in patients with acute myocardial infarction. J Cardiol 2009;54:36-44.

Abbo KM, Dooris M, Glazier S, O'Neill WW, Byrd D, Grines CL, Safian RD. Features and outcome of no-reflow after percutaneous coronary intervention. Am J Cardiol 1995;75:778-782.

Resnic FS, Wainstein M, Lee MK, Behrendt D, Wainstein RV, Ohno-Machado L, Kirshenbaum JM, Rogers CD, Popma JJ, Piana R. No-reflow is an independent predictor of death and myocardial infarction after percutaneous coronary intervention. Am Heart J 2003;145:42-46.

Kassaian SE, Sahebjam M, Salarifar M, Alidoosti M, Zeinali AH, Saleh DK, Poorhoseini H, Paydari N, Davoodi G, Mahmoodian M. Predictors of long-term outcome in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a single center registry (THCR). J Teh Univ Heart Ctr 2006;1:155-161.

Safarian H, Alidoosti M, Shafiee A, Salarifar M, Poorhosseini H, Nematipour E. The SYNTAX score can predict major adverse cardiac events following percutaneous coronary intervention. Heart Views 2014;15:99-105.

Sianos G, Papafaklis MI, Serruys PW. Angiographic thrombus burden classification in patients with ST-segment elevation myocardial infarction treated with percutaneous coronary intervention. J Invasive Cardiol 2010;22(10 Suppl B):6B-14B.

Kirma C, Izgi A, Dundar C, Tanalp AC, Oduncu V, Aung SM, Sonmez K, Mutlu B, Ozdemir N, Erentug V. Clinical and procedural predictors of no-reflow phenomenon after primary percutaneous coronary interventions: experience at a single center. Circ J 2008;72:716-721.

Reffelmann T, Kloner RA. The “no-reflow” phenomenon: basic science and clinical correlates. Heart 2002;87:162-168.

Eeckhout E, Kern MJ. The coronary no-reflow phenomenon: a review of mechanisms and therapies. Eur Heart J 2001;22:729-739.

Harrison RW, Aggarwal A, Ou FS, Klein LW, Rumsfeld JS, Roe MT, Wang TY; American College of Cardiology National Cardiovascular Data Registry. Incidence and outcomes of no-reflow phenomenon during percutaneous coronary intervention among patients with acute myocardial infarction. Am J Cardiol 2013;111:178-184.

Yip HK, Chen MC, Chang HW, Hang CL, Hsieh YK, Fang CY, Wu CJ. Angiographic morphologic features of infarct-related arteries and timely reperfusion in acute myocardial infarction: predictors of slow-flow and no-reflow phenomenon. Chest 2002;122:1322-1332.

Limbruno U, De Carlo M, Pistolesi S, Micheli A, Petronio AS, Camacci T, Fontanini G, Balbarini A, Mariani M, De Caterina R. Distal embolization during primary angioplasty: histopathologic features and predictability. Am Heart J 2005;150:102-108.

Svilaas T, Vlaar PJ, van der Horst IC, Diercks GF, de Smet BJ, van den Heuvel AF, Anthonio RL, Jessurun GA, Tan ES, Suurmeijer AJ, Zijlstra F. Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med 2008;358:557-567.

Valgimigli M, Serruys PW, Tsuchida K, Vaina S, Morel MA, van den Brand MJ, Colombo A, Morice MC, Dawkins K, de Bruyne B, Kornowski R, de Servi S, Guagliumi G, Jukema JW, Mohr FW, Kappetein AP, Wittebols K, Stoll HP, Boersma E, Parrinello G; ARTS II. Cyphering the complexity of coronary artery disease using the syntax score to predict clinical outcome in patients with three-vessel lumen obstruction undergoing percutaneous coronary intervention. Am J Cardiol 2007;99:1072-1081.

Kloner RA, Rude RE, Carlson N, Maroko PR, DeBoer LW, Braunwald E. Ultrastructural evidence of microvascular damage and myocardial cell injury after coronary artery occlusion: which comes first? Circulation 1980;62:945-952.

Singh M, Mathew V, Garratt KN, Berger PB, Grill DE, Bell MR, Rihal CS, Holmes DR, Jr. Effect of age on the outcome of angioplasty for acute myocardial infarction among patients treated at the Mayo Clinic. Am J Med 2000;108:187-192.

Trzeciak P, Gierlotka M, Gąsior M, Osadnik T, Hawranek M, Lekston A, Zembala M, Poloński L. In-hospital and 12-month outcomes after acute coronary syndrome treatment in patients aged<40 years of age (from the Polish Registry of Acute Coronary Syndromes). Am J Cardiol 2014;114:175-180.

Hiew C, Williams T, Hatton R, Narasimhan S, O'Connor S, Baker F, McElduff P, Attia J, Collins N. Influence of age on long-term outcome after emergent percutaneous coronary intervention for ST-elevation myocardial infarction. J Invasive Cardiol 2010;22:273-277.

How to Cite
Alidoosti M, Lotfi R, Lotfi-Tokaldany M, Nematipour E, Salarifar M, Poorhosseini H, Jalali A. Correlates of the “No-Reflow” or “Slow-Flow” Phenomenon in Patients Undergoing Primary Percutaneous Coronary Intervention. jthc. 13(3):108-14.
Original Article(s)