The discovery of incretin-based medications represents a major therapeutic advance in the pharmacologic management of Type 2 diabetes (T2DM), as these agents avoid hypoglycemia, weight gain and simplify the management of T2DM. Dipeptidyl peptidase-4 (CD26, DPP4) inhibitors (DPP4i) are the most widely used incretin-based therapy for the treatment of T2DM globally. DPP4i are modestly effective in reducing HbA1c (≈0.5%) and while these agents were synthesized with the understanding of the role that DPP4 plays in prolonging the half-life of incretins such as glucagon like peptide-1 (GLP-1) and gastric inhibitory peptide (GIP), it is now recognized that incretins are only one of many targets of DPP4. The widespread expression of DPP4 on blood vessels, myocardium and myeloid cells and the non-enzymatic function of CD26 as a signaling and binding protein, across a wide range of species, suggest a teleological role in cardiovascular regulation and inflammation. Indeed, DPP4 is up regulated in pro-inflammatory states including obesity, T2DM and atherosclerosis. Consistent with this maladaptive role, the effects of DPP4 inhibition appear to exert a protective role in cardiovascular disease at least in pre-clinical animal models. Although 2 large clinical trials suggest a neutral effect on cardiovascular end-points, current limitations of performing trials in T2DM over a limited time horizon on top of maximal medical therapy, must be acknowledged before rendering judgment on the cardiovascular efficacy of these agents. This review will critically review the science of DPP4 and the effects of DPP4i on the cardiovascular system.