Individuals with type 2 diabetes are more likely to experience a myocardial infarction and have worse outcomes compared with nondiabetic individuals. The underlying pathophysiology of the atherosclerotic process is accentuated but not significantly different in patients with type 2 diabetes. In addition, the prothrombotic state associated with diabetes may also contribute to the higher incidence of and worse prognosis after myocardial infarction. Difficulties of re-establishing vessel patency by thrombolytic or mechanical means due to diffuse coronary disease, altered vessel structure, and prothrombotic state can contribute to the high morbidity and mortality in these patients. The concurrent metabolic dysfunction contributes to impair compensatory mechanisms, which can increase infarct size and cause more impairment of left ventricular function. Aggressive medical therapy and careful modulation of glucose metabolism in the acute and follow-up phase of a myocardial infarction may favorably influence outcome.