Objective: Blood pressure fluctuates during diastole to create a dicrotic wave but the mechanistic origin remains poorly understood. We sought to investigate the characteristics and determinants of diastolic pressure and flow fluctuations with a focus on stiffness gradients between the central aorta and peripheral arteries. Methods: Using applanation tonometry and duplex ultrasound, pulse waveforms were recorded on the femoral artery in 592 patients (age: 55=14years) to estimate the diastolic pressure fluctuation as a residual wave against the mono-exponential decay and the diastolic flow fluctuation as a bidirectional (forward and reverse) velocity wave. The radial, carotid, and dorsalis pedis pressures were also recorded to measure the peripheral/aortic pulse pressure (PP) and pulse wave velocity (PWV) ratios. Results: There were close resemblances between the femoral pressure and flow fluctuation waveforms. The pressure and flow fluctuations were mutually correlated in relative amplitude as indexed to the total pulse height (r=0.63), and the former temporally followed the latter. In multivariate-adjusted models, higher peripheral/aortic PP and PWV ratios were independently associated with greater pressure and flow fluctuation indices (P<0.001). Mediation analysis revealed that the associations of PP and PWV ratios with the pressure fluctuation index were largely mediated by the flow fluctuation index [indirect/total effect ratio: 57 (95% CI 42–80)% and 54 (30–100)%, respectively]. Conclusion: These results suggest that central-to-peripheral pulse amplification and stiffness gradients contribute to triphasic flow fluctuations and dicrotic pressure waves. Diminished or inverted stiffness gradients caused by aortic stiffening may thus reduce diastolic runoff leading to ischemic organ damage.