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cardio.stemi.no-reflow.v1PRODUCTION
cardio.stemi.no-reflow.v1

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

cardiologyacuteadult
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10/12 authored

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Detailed

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

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no-reflow confirmed

Patient inputs (9)

Older patients have higher microvascular dysfunction and no-reflow rates

Contrast nephropathy risk + DOAC dosing

TIMI thrombus grade ≥4 is the strongest predictor of no-reflow; informs intracoronary pharmacotherapy + selective aspiration decision

TIMI flow grade + myocardial blush grade post-PCI defines no-reflow; quantify residual obstruction

ST resolution >50% at 60-90 min is the bedside surrogate for microvascular reperfusion; persistent ST↑ → no-reflow

Higher troponin peaks correlate with larger MVO area on cardiac MRI; prognostic

LVEF + regional wall motion + LV thrombus + mechanical complications

Hemodynamic compromise from no-reflow → MCS escalation threshold

Cardiac MRI with LGE quantifies microvascular obstruction (MVO as hypoenhancement within LGE) — strongest prognostic marker (van Kranenburg JACC Imaging 2014)

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Severity triggers (4)

4 need judgement
  • informationallife_threateningpersistent_shock_post_pci_no_reflow
    No-reflow + SBP <90 + lactate ≥2 + cool extremities — SCAI C+ shock from microvascular dysfunction
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghemorrhage_from_intracoronary_fibrinolysis
    Bleeding (intracranial, GI, retroperitoneal) following low-dose intracoronary fibrinolysis attempt for refractory no-reflow per REFLO-STEMI approach
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremicrovascular_dysfunction_confirmed_on_cardiac_mri
    Cardiac MRI at 5-7 d shows large MVO area (≥1.5% of LV mass) within LGE — strongest prognostic predictor of adverse remodeling + MACE
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_no_reflow_attempts_during_pci
    Multiple attempts at intracoronary vasodilator delivery without TIMI 3 restoration; consider GP IIb/IIIa inhibitor; selective aspiration if very high thrombus burden
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

No-reflow intracoronary pharmacotherapy axis — adds to parent cardio.stemi.core.v1 regimen
axis: no_reflow_intracoronary_pharmacotherapy
Selected axis "No-reflow intracoronary pharmacotherapy axis — adds to parent cardio.stemi.core.v1 regimen" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg chewed → 81 mg daily • PO • load + daily
    triggers: stemi_with_no_reflow
    AHA 2025 ACS Class I; same as parent
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo
    triggers: stemi_pci_with_no_reflow
    PLATO PMID 19717846; same as parent
    rxcui 1116632
  • adenosine
    rescue
    purine_nucleoside_vasodilator
    50-200 µg intracoronary bolus, multiple boluses • intracoronary • PRN at PCI
    triggers: no_reflow_during_pci
    First-line intracoronary vasodilator for no-reflow per multiple registries; mechanism = adenosine A2 receptor microvascular vasodilation
    rxcui 296
  • nicardipine
    rescue
    calcium_channel_blocker_dihydropyridine
    100-200 µg intracoronary • intracoronary • PRN at PCI
    triggers: no_reflow_persistent_after_adenosine
    Calcium-mediated microvascular vasodilation; alternative when adenosine ineffective or contraindicated
    rxcui 235230
  • verapamil
    rescue
    calcium_channel_blocker_non_dihydropyridine
    100-200 µg intracoronary • intracoronary • PRN at PCI
    triggers: no_reflow_persistent
    Microvascular vasodilation; alternative to nicardipine; caution in bradycardia / heart block
    rxcui 11170
  • nitroprusside
    rescue
    no_donor_vasodilator
    50-200 µg intracoronary • intracoronary • PRN at PCI
    triggers: no_reflow_refractory
    Some institutions use NO-mediated vasodilation; less established than adenosine/CCBs
    rxcui 7476
  • nitroglycerin
    add on
    no_donor_vasodilator
    100-300 µg intracoronary OR 5-200 µg/min IV titrate • IV / intracoronary • PRN
    triggers: no_reflow_during_pci, ongoing_ischemia_post_pci
    Adjunctive epicardial vasodilation; less effective at microvascular level than adenosine
    rxcui 4917
  • unfractionated heparin
    first line
    heparin_unfractionated
    70-100 U/kg IV bolus • IV • bolus + infusion
    triggers: stemi_pci_planned
    AHA 2025 Class I; same as parent
    rxcui 5224
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO • daily
    triggers: stemi_confirmed
    PROVE-IT PMID 15007110; pre-PCI statin loading may reduce no-reflow per ARMYDA-RECAPTURE meta-analyses
    rxcui 83367

outpatient playbook — drug actions (1)

  1. 1. continue secondary-prevention bundle
    rxcui 243670
    ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + GDMT • PO • as scheduled
    trigger: post-no-reflow STEMI
    AHA 2025

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: TIMI flow ≤2 OR myocardial blush grade 0-1 despite patent epicardial coronary post-PCI; 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**STEMI post-PCI no-reflow phenomenon (TIMI ≤2 despite patent epicardial vessel)** (cardio.stemi.no-reflow.v1).
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **No-reflow intracoronary pharmacotherapy axis — adds to parent cardio.stemi.core.v1 regimen**.
1. aspirin 162-325 mg chewed → 81 mg daily PO load + daily (antiplatelet_cox1, first line) — AHA 2025 ACS Class I; same as parent
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo (p2y12_inhibitor, first line) — PLATO PMID 19717846; same as parent
3. adenosine 50-200 µg intracoronary bolus, multiple boluses intracoronary PRN at PCI (purine_nucleoside_vasodilator, rescue) — First-line intracoronary vasodilator for no-reflow per multiple registries; mechanism = adenosine A2 receptor microvascular vasodilation
4. nicardipine 100-200 µg intracoronary intracoronary PRN at PCI (calcium_channel_blocker_dihydropyridine, rescue) — Calcium-mediated microvascular vasodilation; alternative when adenosine ineffective or contraindicated
5. verapamil 100-200 µg intracoronary intracoronary PRN at PCI (calcium_channel_blocker_non_dihydropyridine, rescue) — Microvascular vasodilation; alternative to nicardipine; caution in bradycardia / heart block
6. nitroprusside 50-200 µg intracoronary intracoronary PRN at PCI (no_donor_vasodilator, rescue) — Some institutions use NO-mediated vasodilation; less established than adenosine/CCBs
7. nitroglycerin 100-300 µg intracoronary OR 5-200 µg/min IV titrate IV / intracoronary PRN (no_donor_vasodilator, add on) — Adjunctive epicardial vasodilation; less effective at microvascular level than adenosine
8. unfractionated heparin 70-100 U/kg IV bolus IV bolus + infusion (heparin_unfractionated, first line) — AHA 2025 Class I; same as parent
9. atorvastatin 80 mg PO daily (statin_high_intensity, first line) — PROVE-IT PMID 15007110; pre-PCI statin loading may reduce no-reflow per ARMYDA-RECAPTURE meta-analyses

Setting playbook (outpatient) — Long-term cardiology surveillance: 40-90d LVEF re-echo for ICD eligibility (MVO patients have higher rate of EF decline + ICD eligibility); cardiac rehab completion; secondary prevention bundle maintenance
10. continue secondary-prevention bundle ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + GDMT PO as scheduled — post-no-reflow STEMI (AHA 2025)

Non-pharmacologic actions:
- ICD/WCD adherence
- Cardiac rehab maintenance phase

AVOID / contraindication checks:
- Adenosine_avoid_high_grade_av_block_without_pacing (FDA label)
- Verapamil_avoid_severe_lv_dysfunction_or_av_block (FDA label)
- Nitroprusside_avoid_severe_renal_impairment_thiocyanate_toxicity (FDA label)
- Nitroglycerin_avoid_pde5_inhibitor_use_within_24 48h (FDA label)
- No_routine_aspiration_thrombectomy_per_TASTE_TOTAL (PMID 23981054, 25853743)

Monitoring

Regimen monitoring:
- continuous ecg during intracoronary drug delivery (transient AV block with adenosine)
- TIMI flow grade post each intracoronary bolus (target TIMI 3 + MBG 2-3)
- ST resolution at 60-90 min post pci (>50% resolution = adequate microvascular reperfusion)
- cardiac MRI at 5-7d for MVO quantification if available (prognostic)
- echo at 5-7d for lv thrombus screen

Setting (outpatient) monitoring:
- Quarterly + annual EF + lipid

Follow-up plan: 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
- Close-out criterion: ICD/WCD pathway + cardiac rehab booked

Monitoring phase: 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)

Disposition

Current setting: outpatient — Long-term cardiology surveillance: 40-90d LVEF re-echo for ICD eligibility (MVO patients have higher rate of EF decline + ICD eligibility); cardiac rehab completion; secondary prevention bundle maintenance

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if HFrEF persists

Escalation triggers (move to higher acuity):
- ICD therapy delivered → urgent EP
- EF declining despite GDMT → advanced HF eval

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] No-reflow + SBP <90 + lactate ≥2 + cool extremities — SCAI C+ shock from microvascular dysfunction
- [LIFE_THREATENING] Bleeding (intracranial, GI, retroperitoneal) following low-dose intracoronary fibrinolysis attempt for refractory no-reflow per REFLO-STEMI approach
- [SEVERE] Cardiac MRI at 5-7 d shows large MVO area (≥1.5% of LV mass) within LGE — strongest prognostic predictor of adverse remodeling + MACE

Citations

- 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + TASTE / TOTAL (no routine aspiration thrombectomy) [PMID:23981054](https://pubmed.ncbi.nlm.nih.gov/23981054/)
- Cited evidence (PMID 25853743) [PMID:25853743](https://pubmed.ncbi.nlm.nih.gov/25853743/)
- Cited evidence (PMID 37622670) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 38587234) [PMID:38587234](https://pubmed.ncbi.nlm.nih.gov/38587234/)

Last reconciled with current guidelines: 2026-05-15.
References