Background: No-reflow is a major problem during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI), which is linked to poor myocardial reperfusion and unfavorable outcomes. Unmasking predictors of no-reflow could guide preventive strategies and enhance patient prognosis. We aimed to assess the no-reflow phenomenon's angiographic, clinical and procedural predictors in STEMI patients receiving primary PCI. Methods: 66 STEMI patients who received primary PCI at Zagazig University Hospitals between November 2022 and May 2023 were included in this cross-sectional analysis. Patients were divided into two groups according to whether no-reflow occurred during PCI. Angiographic information, baseline clinical features, and procedure specifics were documented. Binary logistic regression analysis was used in the statistical study to determine the independent predictors of no-reflow. Results: No-reflow occurred in 30.3% (n=20) of patients. Baseline troponin levels were higher in the no-reflow group (684.8±181.6 ng/L vs. 531±196.1 ng/L, p=0.004). The absence of pre-stenting TIMI 3 flow (40% vs. 80.4%, p=0.001), greater number of stents (1.5±0.6 vs. 1.1±0.3, p=0.012) and more frequent use of non-compliant (NC) balloons (80% vs. 23.9%, p<0.001) were more associated with no-reflow. The use of NC balloons was the most robust independent predictor (OR 9.91; 95% CI: 1.90–51.84; p=0.007), followed by pre-stenting absent TIMI 3 flow (OR 0.149; 95% CI: 0.030–0.731; p=0.019). Conclusion: NC balloons’ use and lack of TIMI 3 flow before stenting are independent predictors of no-reflow during primary PCI. Careful procedural planning and early risk identification are essential to minimize this complication and optimize reperfusion outcomes.