Atherosclerosis is the leading cause of death among individuals with type 2 diabetes, accounting for 80% of all mortality among affected individuals. The prediabetic state of insulin resistance, with its accompanying central adiposity, dyslipidemia, and hypertension, is thought to contribute to the development of cardiovascular disease in type 2 diabetes. This chapter summarizes (1) the pathophysiology of the prediabetic state, (2) use of the metabolic syndrome as a clinical proxy for the presence of insulin resistance, and (3) the prediabetic state (metabolic syndrome) as a predictor of cardiovascular disease, highlighting hypertension, dyslipidemia, and impaired glucose metabolism as the strongest predictors. Dyslipidemia, hypertension, and hyperglycemia are highlighted as important targets in cardiovascular disease prevention in type 2 diabetes. Current controversies regarding the glycemic target for cardiovascular disease prevention in diabetes are discussed in light of recently published clinical trials. Other direct cardiovascular effects of diabetes are highlighted, including left ventricular dysfunction, endothelial dysfunction, arterial stiffness, and systemic inflammation.