Diabetes is associated with accelerated atherosclerotic macrovascular disease affecting arteries that supply the heart, brain, and lower extremities. As a consequence, patients with diabetes have a much higher risk of myocardial infarction, stroke, and limb amputation. The excess risk associated with diabetes remains even after adjustment for traditional coronary heart disease risk factors such as smoking, hypertension, and hypercholesterolemia. Type 2 diabetic patients without a previous myocardial infarction have as high a risk of myocardial infarction over 7 years as nondiabetic patients with a previous myocardial infarction. Type 1 diabetes results in nearly 100% atherosclerosis by the fifth decade of life. The mechanisms by which diabetes confers this increased risk are much less clear than those responsible for diabetic microvascular disease, but associational studies suggest that the metabolic derangements caused by insulin resistance and insulin deficiency are involved. These include dyslipoproteinemia, excess free fatty acid flux, and hyperglycemia. In this chapter we review recent findings on the mechanisms whereby high glucose and high FFAs, present in both type 1 and type 2 diabetes, lead to vascular dysfunction and injury. Pathways involving advanced glycation end products, protein kinase C, NF‐κB, aldose reductase, hexosamine, and CREB (cAMP response element binding protein) are reviewed. Both hyperglycemia and high free fatty acid flux lead to increased vascular oxidative stress, which appears to activate all of these signaling pathways, leading to diabetic macrovascular disease.