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No-Reflow Prediction in Acute Coronary Syndrome During Percutaneous Coronary Intervention: The NORPACS Risk Score

Dawson, Luke P.; Rashid, Muhammad; Dinh, Diem T.; Brennan, Angela; Bloom, Jason E.; Biswas, Sinjini; Lefkovits, Jeffrey; Shaw, James A.; Chan, William; Clark, David J.; Oqueli, Ernesto; Hiew, Chin; Freeman, Melanie; Taylor, Andrew J.; Reid, Christopher M.; Ajani, Andrew E.; Kaye, David M.; Mamas, Mamas A.; Stub, Dion; and BCIS Investigators, on behalf of the MIG


Luke P. Dawson

Diem T. Dinh

Angela Brennan

Jason E. Bloom

Sinjini Biswas

Jeffrey Lefkovits

James A. Shaw

William Chan

David J. Clark

Ernesto Oqueli

Chin Hiew

Melanie Freeman

Andrew J. Taylor

Christopher M. Reid

Andrew E. Ajani

David M. Kaye

Dion Stub

on behalf of the MIG and BCIS Investigators


Suboptimal coronary reperfusion (no reflow) is common in acute coronary syndrome percutaneous coronary intervention (PCI) and is associated with poor outcomes. We aimed to develop and externally validate a clinical risk score for angiographic no reflow for use following angiography and before PCI.
We developed and externally validated a logistic regression model for prediction of no reflow among adult patients undergoing PCI for acute coronary syndrome using data from the Melbourne Interventional Group PCI registry (2005–2020; development cohort) and the British Cardiovascular Interventional Society PCI registry (2006–2020; external validation cohort).
A total of 30 561 patients (mean age, 64.1 years; 24% women) were included in the Melbourne Interventional Group development cohort and 440 256 patients (mean age, 64.9 years; 27% women) in the British Cardiovascular Interventional Society external validation cohort. The primary outcome (no reflow) occurred in 4.1% (1249 patients) and 9.4% (41 222 patients) of the development and validation cohorts, respectively. From 33 candidate predictor variables, 6 final variables were selected by an adaptive least absolute shrinkage and selection operator regression model for inclusion (cardiogenic shock, ST-segment–elevation myocardial infarction with symptom onset >195 minutes pre-PCI, estimated stent length ≥20 mm, vessel diameter <2.5 mm, pre-PCI Thrombolysis in Myocardial Infarction flow <3, and lesion location). Model discrimination was very good (development C statistic, 0.808; validation C statistic, 0.741) with excellent calibration. Patients with a score of ≥8 points had a 22% and 27% risk of no reflow in the development and validation cohorts, respectively.
The no-reflow prediction in acute coronary syndrome risk score is a simple count-based scoring system based on 6 parameters available before PCI to predict the risk of no reflow. This score could be useful in guiding preventative treatment and future trials.


Dawson, L. P., Rashid, M., Dinh, D. T., Brennan, A., Bloom, J. E., Biswas, S., …and BCIS Investigators, O. B. O. T. M. (2024). No-Reflow Prediction in Acute Coronary Syndrome During Percutaneous Coronary Intervention: The NORPACS Risk Score. Circulation: Cardiovascular Interventions, 17(4),

Journal Article Type Article
Acceptance Date Jan 31, 2024
Online Publication Date Mar 15, 2024
Publication Date 2024-04
Deposit Date Jul 9, 2024
Journal Circulation: Cardiovascular Interventions
Print ISSN 1941-7640
Electronic ISSN 1941-7632
Publisher American Heart Association
Peer Reviewed Peer Reviewed
Volume 17
Issue 4
Public URL
Additional Information Received: 2023-10-18; Accepted: 2024-01-31; Published: 2024-03-15