The relative impact of diabetes on cardiovascular mortality is steadily increasing. The manifestations of heart disease have an incidence several times higher in diabetic patients than in their nondiabetic counterparts. This is complicated by a specific risk factor complex (hypertension; dyslipidemia; and autonomic, platelet, and coagulation dysfunction) that requires incorporation into study design and routine therapeutics. The physiological specificity of diabetic cardiomyopathy is diastolic dysfunction. The inability to increase myocardial blood flow in response to ischemia even in the absence of overt heart disease is independently related to long- and short-term blood glucose control. This forms the rationale for aggressive metabolic management of acute events with insulin-glucosepotassium infusion, combined with therapeutic strategies such as preferential β-blockade with ACE inhibitor cover for the increased risk of heart failure in infarction, and the deployment of the same risk factor interventions as in nondiabetics, only to markedly tighter targets: blood pressure control ≤140/80 mm Hg, platelet stabilizing and fibrinolytic therapy, lipid-lowering therapy, and revascularization of multivessel disease, preferentially with bypass surgery. However, all such strategies require urgent ongoing review in prospective clinical trials prestratified for diabetes, while patients themselves deserve better structured cooperation between diabetologists and cardiologists...