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To the Editor:We read with interest the article by Mitchell et al1 and agree that flow-mediated dilation (FMD%) response may be partially explained by shear stress (diastolic shear stress [DSS]) or flow changes.2 However, this does not necessarily mean that risk factors do not influence the vascular response. Indeed, Megnien et al3 showed that shear stress reduction provokes different diameter changes in hypercholesterolemic compared with normal subjects. Moreover, experiments performed by our group (M. Laclaustra et al, unpublished data, 2003) on healthy male subjects showed that HDL-cholesterol level was the strongest predictor of FMD% among all lipid variables considered in the study. This finding was actually apparent after controlling by average flow velocity during the first minute of hyperemia (model’s R 2=0.173). Thus FMD% may have a greater sensitivity to detect the effects of risk factor modification than shear stress, as shown in previous articles, including the one incorporating the very first description of the flow-mediated dilation technique.4 Indeed, in those reports, significant differences among groups were found for FMD% values but not for hyperemic flow values.Mitchell et al1 rightly point out that the fact that brachial artery diameter was included in the equations used for calculations of FMD% …

Flow-Mediated Dilation: Just a Marker of Local Shear Stress?