The predicted global epidemic of type 2 diabetes highlights the importance of identifying the most effective ways to reduce the risk of long-term diabetic complications. Although hyperglycaemia is undoubtedly a risk factor for microvascular complications, intensive glycaemic management has delivered only modest improvements in macrovascular endpoints thus far. A multidisciplinary approach addressing the components of the dysmetabolic syndrome, including insulin resistance, dyslipidaemia, hypertension, obesity and impaired fibrinolysis, will be required to protect the cardiovascular system more effectively. The potential vascular protective effects of metformin, demonstrated by the UK Prospective Diabetes Study, may complement other strategies within such a framework.