Cardiovascular disease is frequent and is the main cause of death in type 2-diabetic patients. Hyperinsulinaemia is a risk factor for cardiovascular disease, and insulin accelerates many of the processes leading to atherosclerosis. Studies in type 2-diabetic patients show that high insulin levels correlate with cardiovascular disease and overall mortality. A recent pilot study showed that intensive versus traditional insulin treatment increased the incidence of cardiovascular disease. Therefore treatment regimens that reduce insulin levels should be preferred, at least when equal glucose levels are achieved. In this perspective metformin is the drug of choice. Insulin treatment should be considered only when combined treatment with metformin and sulfonylurea is contraindicated or leads to insufficient blood glucose control. Special caution should be shown with insulin treatment in patients with cardiovascular disease.