Background: In the study of coronary artery disease, the mechanisms underlying atherosclerosis initiation and progression or regression remain incompletely understood. Our research conceptualized the cardiovascular system as an integrated network of pumps and pipes, advocating for a paradigm shift from static imaging of coronary stenosis to dynamic assessments of coronary flow. Further review of fluid mechanics highlighted the water hammer phenomenon as a compelling analog for processes in coronary arteries. Methods: In this review, the analytical methodology employed a comprehensive, multifaceted approach that incorporated a review of fluid mechanics principles, in vitro acoustic experimentation, frame-by-frame visual angiographic assessments of in vivo coronary flow, and an artificial intelligence (AI) protocol designed to analyze the water hammer phenomenon within an acoustic framework. In the analysis of coronary flow, the angiograms were selected from patients with unstable angina if they had previously undergone one or more coronary angiograms, allowing for a longitudinal comparison of dynamic flow and phenomena. Results: The acoustic investigations pinpointed pockets of contrast concentrations, which might correspond to compression and rarefaction zones. Compression antinodes were correlated to severe stenosis, due to rapid shifts from low-pressure diastolic flow to high-pressure systolic surges, resulting in intimal injury. Rarefaction antinodes were correlated with milder lesions, due to de-escalating transitions from high systolic pressure to lower diastolic pressure. The areas of nodes remained without lesions. Based on the locations of antinodes and nodes, a coronary acoustic action map was constructed, enabling the identification of existing lesions, forecasting the progression of current lesions, and predicting the development of future lesions. Conclusions: The results suggested that intimal injury was likely induced by acoustic retrograde pressure waves from the water hammer phenomenon and developed new lesions at specifically exact locations.

In coronary artery disease (CAD), the initiation, progression, and regression of atherosclerosis remain incompletely understood, limiting the effectiveness of specific diagnostic and personalized medicine management strategies based on current imaging and assessment methods. In this scientific rationale and study design analysis, the framework conceptualizes the cardiovascular system as an integrated hydraulic network of pumps and pipes, advancing a shift from static imaging of luminal stenosis toward dynamic assessment of coronary flow. Grounded in fluid mechanics and acoustic principles, this analysis establishes a scientific rationale for an angiographic investigation of hemodynamic disturbances that compromise endothelial integrity in coronary arteries. The first section examines injury arising from repetitive flexion and extension of coronary segments driven by left ventricular contraction, most prominent at the transition from diastole to systole. The second section evaluates the hypothetical effects of thickened boundary layers and intimal injury caused by oxygen deprivation along the proximal portion of the outer curvature of side branches. The third section explores the hypothetical role of recirculating flow in accelerating lesion development at these sites. The fourth section presents an acoustic-based diagnostic framework for assessing the hypothetical impact of retrograde pressure-wave propagation associated with water-hammer phenomena. Collectively, these mechanisms establish the systematic codification and spatial delineation of coronary lesions as represented on the coronary acoustic map. Building on these insights, the present analysis proposes a clinical trial framework integrating AI-driven algorithmic protocols to rigorously assess the diagnostic performance and predictive accuracy of the coronary acoustic map.