Strategies to Prevent the No-Reflow Phenomenon in Primary PCI: A Comprehensive Review

Abstract

The no-reflow phenomenon, defined as inadequate myocardial tissue perfusion despite successful epicardial coronary artery recanalization during primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI), remains a significant clinical challenge associated with increased infarct size, adverse ventricular remodeling, and higher morbidity and mortality. Its multifactorial pathophysiology involves distal embolization of thrombotic and atheromatous debris, ischemia-reperfusion injury, endothelial dysfunction, microvascular spasm, and capillary plugging by inflammatory cells. A complication associated with increased morbidity and mortality due to impaired myocardial salvage and adverse left ventricular remodeling. This comprehensive review aims to synthesize current evidence on the pathophysiology, risk factors, and preventive strategies for no-reflow during primary PCI. Pharmacological interventions such as intracoronary vasodilators, antiplatelet agents, and novel therapies are examined alongside mechanical approaches including thrombus aspiration and distal protection devices. Additionally, the role of procedural techniques, such as optimized stent deployment and ischemic conditioning, is discussed. Emphasis is placed on early identification of high-risk patients and tailored therapeutic strategies to minimize no-reflow incidence. Future directions focusing on emerging biomarkers and advanced imaging techniques to predict and monitor no-reflow are also explored. By consolidating existing knowledge and highlighting evolving practices, this review seeks to guide clinicians in optimizing outcomes in primary PCI by effectively preventing no-reflow.