Nicorandil Balloon Fails to Cut Heart Blockages
A randomized trial found prolonged balloon predilation with intracoronary Nicorandil did not significantly reduce slow-flow or no-reflow in STEMI patients.
Updated on Nov. 3, 2026 in Heart Disease
The TomorrowLAND trial randomized 174 patients with type 1 STEMI to PCI with perfusion balloon or direct stenting. The primary endpoint of slow-flow or no-reflow occurred in 48.8% of the perfusion balloon group and 54.2% of the direct stenting group.
Why it matters
Slow-flow and no-reflow are complications that can limit blood supply to heart tissue during emergency PCI for heart attacks. The trial's findings indicate that this specific perfusion balloon approach with intracoronary Nicorandil did not improve the primary outcome, though it was associated with fewer strict no-reflow events immediately after stent implantation.
The randomized trial of 174 STEMI patients found a primary endpoint rate of 48.8% for the perfusion balloon group versus 54.2% for direct stenting, a difference that was not statistically significant (p=0.51). Immediate strict no-reflow was lower with the perfusion balloon (6.5% vs. 17.1%, p=0.04), but this difference did not persist on final angiography (4.8% vs. 7.2%, p=0.54).
The players
TomorrowLAND trial
A randomized clinical trial evaluating prolonged perfusion balloon predilation with intracoronary Nicorandil in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.
TCT 2026
The annual Transcatheter Cardiovascular Therapeutics conference, a major international forum where interventional cardiology research is presented.
The details
Researchers randomized patients presenting with type 1 STEMI within 24 hours of symptom onset to either PCI with a perfusion balloon, using the Rx Ryusei device to deliver intracoronary Nicorandil, or direct stenting. The trial's primary measure was slow-flow or no-reflow, defined as a TIMI flow grade below 3 at prespecified angiographic stages.
Timeline
Patients were enrolled within 24 hours of symptom onset.
TomorrowLAND trial findings were presented at TCT 2026.
Roadmap
This trial tests an adjunctive vasodilator strategy aimed at the microvascular complications that persist during primary PCI for STEMI. Its negative primary endpoint places this approach among several interventions tried to reduce no-reflow, without yet establishing a clear clinical benefit.
For patients undergoing emergency PCI for a heart attack, the trial did not show that this perfusion balloon approach improves the primary no-reflow outcome. Patients and clinicians should not expect a change in standard care based on these findings alone.
The takeaway
Reducing microvascular blockage during heart attack treatment remains an open problem, and this trial found no significant benefit from the tested Nicorandil balloon strategy on its primary endpoint. Readers following heart attack care should watch for longer-term clinical results before drawing conclusions.
Further reading
For related coverage of the condition, see Heart Disease.
