Patient handout

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

PRODUCTION

1. Your condition

This handout is for stemi post-pci no-reflow phenomenon (timi ≤2 despite patent epicardial vessel). Your care team identified this based on: timi flow ≤2 or myocardial blush grade 0-1 despite patent epicardial coronary post-pci.

Other reasons your team may use this plan: persistent st elevation (>50% of baseline) at 60-90 min post-pci despite angiographic success; recurrent chest pain post-pci + hemodynamic deterioration → suspect no-reflow.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
aspirin	162-325 mg chewed → 81 mg daily	PO	load + daily	AHA 2025 ACS Class I; same as parent
ticagrelor	180 mg load → 90 mg BID	PO	BID × 12 mo	PLATO PMID 19717846; same as parent
adenosine	50-200 µg intracoronary bolus, multiple boluses	intracoronary	PRN at PCI	First-line intracoronary vasodilator for no-reflow per multiple registries; mechanism = adenosine A2 receptor microvascular vasodilation
nicardipine	100-200 µg intracoronary	intracoronary	PRN at PCI	Calcium-mediated microvascular vasodilation; alternative when adenosine ineffective or contraindicated
verapamil	100-200 µg intracoronary	intracoronary	PRN at PCI	Microvascular vasodilation; alternative to nicardipine; caution in bradycardia / heart block
nitroprusside	50-200 µg intracoronary	intracoronary	PRN at PCI	Some institutions use NO-mediated vasodilation; less established than adenosine/CCBs
nitroglycerin	100-300 µg intracoronary OR 5-200 µg/min IV titrate	IV / intracoronary	PRN	Adjunctive epicardial vasodilation; less effective at microvascular level than adenosine
unfractionated heparin	70-100 U/kg IV bolus	IV	bolus + infusion	AHA 2025 Class I; same as parent
atorvastatin	80 mg	PO	daily	PROVE-IT PMID 15007110; pre-PCI statin loading may reduce no-reflow per ARMYDA-RECAPTURE meta-analyses

Plan: No-reflow intracoronary pharmacotherapy axis — adds to parent cardio.stemi.core.v1 regimen

3. When to call your provider

Contact your care team if any of the following happen:

ICD therapy delivered → urgent EP
EF declining despite the four foundational heart-failure medications → advanced HF eval

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

No-reflow + SBP <90 + lactate ≥2 + cool extremities — SCAI C+ shock from microvascular dysfunction(life-threatening)
Cardiac MRI at 5-7 d shows large MVO area (≥1.5% of LV mass) within LGE — strongest prognostic predictor of adverse remodeling + MACE
Multiple attempts at intracoronary vasodilator delivery without TIMI 3 restoration; consider GP IIb/IIIa inhibitor; selective aspiration if very high thrombus burden
Bleeding (intracranial, GI, retroperitoneal) following low-dose intracoronary fibrinolysis attempt for refractory no-reflow per REFLO-STEMI approach(life-threatening)

5. Follow-up

Cardiology + EP follow-up; heart pumping strength (LVEF) re-echo at 40-90 d for ICD eligibility (MVO patients have higher remodeling rates); cardiac rehab; secondary prevention bundle maintenance

6. Sources

Guideline: 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + TASTE / TOTAL (no routine aspiration thrombectomy)