Cytochrome P450s (P450) metabolize arachidonic acid (AA) to hydroxyeicosatetraenoic acids (HETEs) and epoxyeicosatrienoic acids (EETs). Among these eicosanoids, 20-HETE is formed in a tissue and cell-specific fashion and plays an important role in the regulation of vascular tone in the brain, kidney, heart and splanchnic beds. 20-HETE is a potent vasoconstrictor produced in vascular smooth muscle (VSM) cells. It depolarizes VSM by blocking the open-state probability of Ca2+-activated K+-channels. Inhibitors of the formation of 20-HETE block the myogenic response of renal and cerebral arterioles in vitro and autoregulation of renal and cerebral blood flow in vivo. The formation of 20-HETE in vascular smooth muscle is stimulated by angiotensin II, endothelin and norepinephrine and is inhibited by nitric oxide (NO). 20-HETE also stimulates mitogenic and angiogenic responses in vitro and in vivo. Changes in the production of 20-HETE have been observed in ischemic cerebrovascular diseases, cardiac ischemia-reperfusion injury, kidney diseases, hypertension, diabetes, uremia, toxemia of pregnancy. The physiological and pathophysiological role of 20-HETE in the regulation of vascular tone are being revealed by the use of newly developed inhibitors of the synthesis of 20-HETE and 20-HETE analogs. The present review summarizes recent findings implicating a critical role for 20-HETE in altering cardiovascular function in a variety of pathological conditions.