The endothelium lining the inner surface of blood vessels of the cardiovascular system is constantly exposed to hemodynamic shear stress. The interaction between endothelial cells and hemodynamic shear stress has critical implications for atherosclerosis. Regions of arterial narrowing, curvatures, and bifurcations are especially susceptible to atherosclerotic lesion formation. In such areas, endothelial cells experience low, or oscillatory, shear stress. Corresponding changes in endothelial cell structure and function make them susceptible to the initiation and development of atherosclerosis. In contrast, blood flow with high laminar shear stress activates signal transductions as well as gene and protein expressions that play important roles in vascular homeostasis. In response to laminar shear stress, the release of vasoactive substances such as nitric oxide and prostacyclin decreases permeability to plasma lipoproteins as well as the adhesion of leukocytes, and inhibits smooth muscle cell proliferation and migration. In summary, different flow patterns directly determine endothelial cell morphology, metabolism, and inflammatory phenotype through signal transduction and gene and protein expression. Thus, high laminar shear stress plays a key role in the prevention of atherosclerosis through its regulation of vascular tone and long-term maintenance of the integrity and function of endothelial cells.