Prediction of no-reflow phenomenon in elective percutaneous coronary intervention for non-acute myocardial infarction

Q: What are the key findings of this study?

Elective PCI in non-AMI patients had a 2.4% incidence of no-reflow, independently predicted by atrial fibrillation (OR 2.20), male sex (OR 2.08), and device oversizing (OR 14.4), with smoking inversely associated (OR 0.53).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Patients undergoing elective percutaneous coronary intervention for non-acute myocardial infarction (n=3904). Intervention: Elective percutaneous coronary intervention vs. No-reflow vs no no-reflow groups. Primary outcome: Incidence of angiographic no-reflow phenomenon defined as TIMI flow grade 1.1, OR 0.53 for current/former smoking, 95% CI 95% CI 1.08-4.49 (atrial fibrillation), 1.15-3.74 (male sex), 3.71-56.1 (device-to-vessel ratio), 0.32-0.89 (smoking), p=0.031 (atrial fibrillation), 0.015 (male sex), <0.001 (device-to-vessel ratio), 0.017 (smoking)).

Q: What does this research mean for the field?

Atrial fibrillation, male sex, and stent oversizing are independent predictors of the no-reflow phenomenon in elective percutaneous coronary intervention for non-acute myocardial infarction patients. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

Ho Sung Jeon; Young Jin Youn; Tae Sic Lee; Su Yong Kim; Sang Jun Lee; Se-Eun Kim; Jung-Hee Lee; Young Jun Park; Jung-Woo Son; Jun-Won Lee; Min-Soo Ahn; Sung Gyun Ahn; Jang‐Young Kim; Jun‐Won Lee

doi:10.1186/s12872-026-05647-6

March 3, 2026BMC Cardiovascular DisordersOpen Access

Prediction of no-reflow phenomenon in elective percutaneous coronary intervention for non-acute myocardial infarction

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Key result

Device oversizing linked to ~14-fold higher no-reflow risk during elective PCI.

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Key Points

To examine the incidence, clinical and procedural predictors, and clinical impact of the no-reflow phenomenon in patients undergoing elective percutaneous coronary intervention for non-acute myocardial infarction.
Analyzed 3,904 non-AMI patients undergoing elective PCI selected from a single-center prospective PCI registry of 10,801 patients between 2013 and 2024.
Identified independent predictors using multivariable logistic regression with cluster-robust standard errors and evaluated predictive performance using machine learning models (XGBoost, Random Forest, LightGBM).
Angiographic no-reflow occurred in 94 of 3,904 patients (2.4%) and was associated with elevated rates of periprocedural cardiogenic shock (26.6% vs. 1.3%, p < 0.001) and in-hospital mortality (1.1% vs. 0.1%, p = 0.071).
Independent predictors of no-reflow included a device-to-vessel ratio > 1.1 (OR 14.4, 95% CI 3.71–56.1, p < 0.001), atrial fibrillation (OR 2.20, 95% CI 1.08–4.49, p = 0.031), and male sex (OR 2.08, 95% CI 1.15–3.74, p = 0.015), whereas smoking history was inversely associated (OR 0.53, 95% CI 0.32–0.89, p = 0.017).
Machine learning models exhibited limited predictive utility due to event rarity, while 1-year patient-oriented and device-oriented composite outcomes showed no significant differences between groups.

Study Design

Type

Cohort (n=3,904)

Multicenter

No

Structured PICO

P

Population

3,904 patients with non-acute myocardial infarction (non-AMI) who underwent elective percutaneous coronary intervention (PCI) from a single-center prospective registry (2013–2024) in South Korea.

I

Intervention

Elective percutaneous coronary intervention (PCI)

C

Comparator

Patients without no-reflow

O

Outcome

Incidence and predictors of no-reflow (defined as transient or persistent thrombolysis in myocardial flow < 3 without proximal obstruction)surrogate

Main Result

Effect estimate: OR 2.20 for atrial fibrillation, OR 2.08 for male sex, OR 14.4 for device-to-vessel ratio >1.1, OR 0.53 for current/former smoking (95% CI 95% CI 1.08-4.49 (atrial fibrillation), 1.15-3.74 (male sex), 3.71-56.1 (device-to-vessel ratio), 0.32-0.89 (smoking))

Absolute Event Rate: 2.4% vs 97.6%

p-value: p=0.031 (atrial fibrillation), 0.015 (male sex), <0.001 (device-to-vessel ratio), 0.017 (smoking)

In patients undergoing elective PCI for non-AMI, no-reflow is an infrequent (2.4%) but clinically relevant complication independently predicted by atrial fibrillation, male sex, and stent oversizing.

Limitations

Single-center study limits generalizability
Low event rate of no-reflow limits predictive model performance
Machine learning models showed limited predictive accuracy due to rarity of events
Single-center observational study with potential unmeasured confounders
No-reflow defined solely by angiographic assessment without objective microvascular indices
Lesion characteristics assessed using angiography rather than intravascular imaging
Lack of detailed data on pre-procedural statin loading or statin intensity
Limited performance of machine learning models due to low event rate
Unexpected associations for sex and smoking status likely reflecting residual confounding

Discussion

No takes yet. Share an insight, caveat, or question.

Implication

May warrant caution against device oversizing in male AF patients during elective PCI; challenges prior no-reflow studies confined to AMI.

Abstract

While the ‘no-reflow’ phenomenon is a well-recognized complication of acute myocardial infarction (AMI), its incidence, predictors, and clinical implications in patients undergoing elective percutaneous coronary intervention (PCI) for non-AMI remain insufficiently characterized. We investigated the clinical and procedural predictors of the no-reflow in patients undergoing elective PCI for non-AMI. Among 10,801 patients in a single-center prospective PCI registry (2013–2024), 3,904 patients with non-AMI who underwent elective PCI were included. No-reflow was defined as transient or persistent thrombolysis in myocardial flow < 3 without proximal obstruction. Independent predictors were identified using multivariable logistic regression with cluster-robust standard errors. Machine learning (ML) models were also developed to assess predictive performance. No-reflow was observed in 94 (2.4%) patients. No-reflow was associated with more complex lesions and higher rates of procedural complication rates. Independent predictors of no-reflow included atrial fibrillation (odds ratio [OR] 2.20, 95% confidence interval [CI] 1.08–4.49, p = 0.031), male sex (OR 2.08, 95% CI 1.15–3.74, p = 0.015), and a device-to-vessel ratio > 1.1 (OR 14.4, 95% CI 3.71–56.1, p < 0.001), while current or former smoking was inversely associated (OR 0.53, 95% CI 0.32–0.89, p = 0.017). Although ML models were developed to predict no-reflow, their performance was limited owing to the rarity of events. No-reflow is an infrequent but clinically relevant complication of elective PCI for patients with non-AMI. Atrial fibrillation, male sex, and stent oversizing were independent predictors, whereas smoking history was inversely associated. These findings underscore the importance of procedural planning and individualized risk assessment in non-AMI PCI.

Cite This Study

Jeon et al. (2026) conducted a cohort in Patients undergoing elective percutaneous coronary intervention for non-acute myocardial infarction (n=3,904). Elective percutaneous coronary intervention vs. No-reflow vs no no-reflow groups was evaluated on Incidence of angiographic no-reflow phenomenon defined as TIMI flow grade <3 without mechanical obstruction following elective PCI (OR 2.20 for atrial fibrillation, OR 2.08 for male sex, OR 14.4 for device-to-vessel ratio >1.1, OR 0.53 for current/former smoking, 95% CI 95% CI 1.08-4.49 (atrial fibrillation), 1.15-3.74 (male sex), 3.71-56.1 (device-to-vessel ratio), 0.32-0.89 (smoking), p=0.031 (atrial fibrillation), 0.015 (male sex), <0.001 (device-to-vessel ratio), 0.017 (smoking)). Elective PCI in non-AMI patients had a 2.4% incidence of no-reflow, independently predicted by atrial fibrillation (OR 2.20), male sex (OR 2.08), and device oversizing (OR 14.4), with smoking inversely associated (OR 0.53).

synapsesocial.com/papers/69a91d8dd6127c7a504c0636 https://doi.org/10.1186/s12872-026-05647-6

Topics

Percutaneous coronary intervention

Coronary artery disease

Atrial fibrillation

Persistent AF management

Chronic total occlusion PCI

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Prediction of no-reflow phenomenon in elective percutaneous coronary intervention for non-acute myocardial infarction

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Discussion

Implication

Abstract

Cite This Study

Topics

Prediction of no-reflow phenomenon in elective percutaneous coronary intervention for non-acute myocardial infarction

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Discussion

Implication

Abstract

Cite This Study

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