The no-reflow phenomenon, a complex complication arising post-successful coronary revascularization, presents a big challenge in the management of acute myocardial infarction. This comprehensive review explores the complex aspects of a condition called "no-reflow", exploring its incidence, pathophysiology, predictors, clinical impact, diagnosis, and management strategies. Despite advancements in investigative and therapeutic approaches, a comprehensive understanding of the precise mechanisms in humans remains elusive.

The article addresses the varied incidence of no-reflow across clinical settings, ranging from 2% in elective native coronary interventions to 26% in primary percutaneous coronary interventions for acute myocardial infarction. Notably, up to 60% of ST-elevation myocardial infarction patients undergoing primary PCI experience no-reflow even after optimal coronary vessel reperfusion. The pathophysiology encompasses ischemia-reperfusion injury, distal microthromboembolism, and endothelial dysfunction, categorized into structural and functional types. Predictors, including age, reperfusion time, blood pressure, thrombus burden, and vessel diameter emphasize the importance of tools for assessing risks.

No-reflow significantly impacts left ventricular function and remodeling leading to prolonged hospitalization durations and heightened long-term mortality. Diagnosis relies on crucial modalities such as coronary angiography and cardiac magnetic resonance imaging.

Management strategies encompass prevention through optimizing door-to-balloon time, blood glucose, and blood pressure control, along with various treatment options like thrombus aspiration, glycoprotein IIb/IIIa inhibitors, nitroprusside, calcium channel blockers, and adenosine.

This review provides a detailed viewpoint on the complex nature of the no-reflow phenomenon, emphasizing the persistent need for research to enhance outcomes in patients undergoing coronary interventions.