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cardio.stemi.no-reflow.v1

STEMI post-PCI no-reflow phenomenon (TIMI ≤2 despite patent epicardial vessel)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E temporal-context variant of cardio.stemi.core.v1 — covers post-PCI no-reflow phenomenon (TIMI ≤2 OR MBG 0-1 despite patent epicardial coronary). Mechanisms: distal embolization (thrombus + plaque debris), microvascular obstruction (MVO on cardiac MRI), reperfusion injury (oxidative stress + calcium overload + neutrophil activation). Predictors: high thrombus burden (TIMI thrombus grade ≥4), large vessel, anterior MI, late presenter, prior MI, diabetes. Treatment: intracoronary adenosine 50-200 µg multiple boluses (first-line), nicardipine 100-200 µg, verapamil 100-200 µg, nitroprusside 50-200 µg (some institutions), IV nitroglycerin. Aspiration thrombectomy NOT routinely beneficial per TASTE (PMID 23981054) + TOTAL (PMID 25853743) — reserve for very high thrombus burden after wire crossing. IABP / Impella consideration if hemodynamic compromise. Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent (no-reflow-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (3)

  • imaging
    TIMI flow ≤2 OR myocardial blush grade 0-1 despite patent epicardial coronary post-PCI
    angiographic_no_reflow_post_pci
  • imaging
    Persistent ST elevation (>50% of baseline) at 60-90 min post-PCI despite angiographic success
    persistent_st_elevation_post_successful_pci
  • symptom
    Recurrent chest pain post-PCI + hemodynamic deterioration → suspect no-reflow
    recurrent_chest_pain_post_pci_with_hemodynamic_change

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Older patients have higher microvascular dysfunction and no-reflow rates
  • thrombus_burden_at_pcirequired
    history • used at INITIAL_WORKUP
    TIMI thrombus grade ≥4 is the strongest predictor of no-reflow; informs intracoronary pharmacotherapy + selective aspiration decision
  • cor_angio_post_pcirequired
    imaging • used at INITIAL_WORKUP
    TIMI flow grade + myocardial blush grade post-PCI defines no-reflow; quantify residual obstruction
  • ecg_post_pcirequired
    imaging • used at INITIAL_WORKUP
    ST resolution >50% at 60-90 min is the bedside surrogate for microvascular reperfusion; persistent ST↑ → no-reflow
  • sbprequired
    vital • used at RED_FLAGS
    Hemodynamic compromise from no-reflow → MCS escalation threshold
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Higher troponin peaks correlate with larger MVO area on cardiac MRI; prognostic
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy risk + DOAC dosing
  • cardiac_mri_with_lge
    imaging • used at MONITORING
    Cardiac MRI with LGE quantifies microvascular obstruction (MVO as hypoenhancement within LGE) — strongest prognostic marker (van Kranenburg JACC Imaging 2014)
  • echo_post_pcirequired
    imaging • used at MONITORING
    LVEF + regional wall motion + LV thrombus + mechanical complications

12-phase flow (10)

  1. 1FRAME
    No-reflow = TIMI ≤2 OR MBG 0-1 despite patent epicardial coronary post-PCI; mechanisms: distal embolization (thrombus + plaque), microvascular obstruction, reperfusion injury; immediate intracoronary intervention required
    inputs: cor_angio_post_pci
    advance: no-reflow confirmed
  2. 2ENTRY
    In-cath-lab recognition; TIMI thrombus grade documentation; intracoronary pharmacotherapy preparation
    inputs: thrombus_burden_at_pci
    advance: cath team aware
  3. 3CONTEXT
    Allergies (esp adenosine, calcium channel blockers), antithrombotic regimen, hemodynamic baseline
    inputs: age, creatinine
    advance: context complete
  4. 4RED_FLAGS
    Persistent shock post-PCI from no-reflow (SCAI C+) → emergent IABP / Impella consideration; hemorrhage from intracoronary fibrinolysis if attempted
    inputs: sbp
    actions: cardiogenic_shock
    advance: shock + bleeding screened
  5. 5INITIAL_WORKUP
    Document TIMI flow + MBG + thrombus grade; ECG for ST resolution; serial troponin
    inputs: cor_angio_post_pci, ecg_post_pci, troponin
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    Intracoronary pharmacotherapy: adenosine 50-200 µg bolus (multiple boluses; first-line); nicardipine 100-200 µg (calcium-channel-mediated vasodilation); verapamil 100-200 µg; nitroprusside 50-200 µg (some institutions); IV nitroglycerin; selective aspiration thrombectomy ONLY if very high thrombus burden after wire crossing per TASTE PMID 23981054 + TOTAL PMID 25853743
    advance: intracoronary therapy delivered
  7. 7TREATMENT
    Standard ACS regimen via cardio.stemi.core.v1 (ASA + P2Y12 + UFH + statin + BB if EF↓); ADD: aggressive intracoronary vasodilator + selective aspiration; consider GP IIb/IIIa inhibitor if very high thrombus burden; IABP/Impella if hemodynamic compromise
    inputs: sbp, creatinine
    actions: protocol.stemi
    advance: no-reflow management bundle delivered
  8. 8DISPOSITION
    CICU post-PCI mandatory; longer monitoring than uncomplicated STEMI; cardiac MRI consideration at 5-7 d
    advance: unit assigned + MRI plan documented
  9. 9MONITORING
    Telemetry, daily exam for new murmur (mechanical complications more common with large infarct); echo at 5-7 d for LV thrombus; cardiac MRI at 5-7 d for MVO quantification (prognostic marker)
    inputs: echo_post_pci, cardiac_mri_with_lge
    actions: panel.cardiac
    advance: MRI + thrombus screen complete
  10. 10FOLLOWUP
    Cardiology + EP follow-up; LVEF re-echo at 40-90 d for ICD eligibility (MVO patients have higher remodeling rates); cardiac rehab; secondary prevention bundle maintenance
    advance: ICD/WCD pathway + cardiac rehab booked