Accelerated progression of coronary atherosclerosis underlies the heightened cardiovascular risk observed in diabetic patients. As the worldwide prevalence of diabetes escalates in association with the incidence of abdominal obesity, the global burden of cardiovascular disease will continue to rise. Therapeutic strategies that have had the greatest cardiovascular benefit in diabetes have focused on lowering LDL-cholesterol and blood pressure, rather than glucose-lowering specifically. More recently, arterial wall imaging has helped characterize the natural history of coronary atherosclerosis in diabetes, the impact of associated risk factors and the influence of medical therapies.