Objectives: The no-reflow phenomenon occurs in 25% of patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and may be associated with adverse outcomes. The aim of our study was to detect novel predictors of no-reflow phenomenon and the resulting adverse long term outcomes. Methods: We enrolled 400 STEMI patients undergoing primary PCI; 228 patients had TIMI flow 3 after PCI (57%) and the remaining 172 patients had TIMI flow <3 (43%). Fibrinogen to albumin ratio (FAR), high sensitive C-reactive protein to albumin ratio (CAR), and atherogenic index of plasma (AIP) were calculated. Long term mortality and morbidity during 6 months follow up were recorded. These data were compared among both groups. Results: In multivariate regression analysis, old age (OR ¼ 1.115, 95% CI: 1.032e1.205, P ¼ 0.006), higher troponin level >5.6 ng/mL (OR ¼ 1.040, 95% CI: 1.001e1.080, P ¼ 0.04), diabetes mellitus (OR ¼ 4.401, 95% CI: 1.081e17.923, P ¼ 0.04) and heavy thrombus burden (OR ¼ 16.915, 95% CI: 5.055e56.602, P < 0.001) could be considered as predictors for the development of no-reflow. Interestingly, CAR >0.21, FAR >11.56, and AIP >0.52 could be considered as novel powerful independent predictors (OR ¼ 3.357, 95% CI: 2.288 e4.927, P < 0.001, OR ¼ 4.187, 95% CI: 2.761e6.349, P < 0.001, OR ¼ 16.794, 95% CI: 1.018e277.01, P ¼ 0.04, respectively). Higher long term mortality (P < 0.001) and heart failure (P < 0.001) was also strongly related to incidence of no-reflow. Conclusion: No-reflow could be attributed to novel predictors as CAR, FAR, and AIP. This phenomenon was associated with long term adverse events as higher mortality and pump failure