Abstract-Flow-mediated dilation of the brachial or radial artery in response to transient hyperaemic flow, the most widely used test of endothelial function, is only manifest after flow decays back to baseline. We examined whether this dissociation of flow and diameter might be explained by a reduction in transmural pressure generated by high flow. Studies were performed in healthy subjects 20 to 55 years of age. Flow-mediated dilation was measured in the radial artery using a standard protocol and after flow interruption at peak hyperemia during brachial artery infusion of saline and the NO synthase inhibitor N G -monomethyl-L-arginine (8 mol/min). Flow interruption 20 seconds after cuff release (during high flow but no dilatation) produced an immediate increase in radial artery diameter of 5.36Ϯ2.12%, inhibited by N G -monomethyl-L-arginine to 1.09Ϯ0.67% (nϭ8; PϽ0.001). Mean intra-arterial radial blood pressure and, hence, transmural pressure fell after cuff release by a mean of 26Ϯ1.8 mm Hg (nϭ6; PϽ0.0001) at the time of peak hyperemic flow. Modulation of transmural pressure within the brachial artery by cuff inflation around the artery demonstrated that this fall is sufficient to reduce arterial diameter by an amount similar to flow-mediated dilation. These results suggest that flow-dependent, NO-dependent dilation is offset by a flow-induced fall in local arterial pressure and, hence, in transmural pressure. Shear related NO release is likely to play a greater role in the short-term regulation of arterial tone than that suggested by flow-mediated dilation. (Hypertension. 2011;57:1145-1150.) Key Words: blood flow velocity Ⅲ blood pressure Ⅲ nitric oxide Ⅲ vasodilation Ⅲ vascular endothelium-dependent relaxation F low-mediated dilation (FMD), the vasodilation of the brachial or radial artery that follows the marked increase in shear stress that occurs during peak hyperaemic flow, is the most widely used noninvasive in vivo test of endothelial function and is predictive of clinical cardiovascular events. [1][2][3] It is thought to result from shear stress activating endothelial NO synthase 4,5 and vasodilation of vascular smooth muscle to endothelium-derived NO. 6 Other mediators may also be involved, but FMD is substantially blocked by inhibition of endothelial NO synthase. 7 Because of the proposed link to shear, it has been proposed that FMD should be referred to as "shear-dependent dilation." However, unless there are changes in diameter much larger than the usual FMD response of 5% to 10%, shear is closely related to flow, and because the term "FMD" remains in widespread use, we retain this abbreviation to avoid confusion. An unresolved paradox is that maximal FMD occurs 30 seconds to 2 minutes after peak hyperaemic flow when flow and shear return almost to baseline, 8,9 whereas NO release in response to shear stress 4 and relaxation to NO when measured in vitro 6 occur within seconds. Furthermore, the relationship between FMD and shear is complex. 5,10 We hypothesized that shear induces an immediate and ...