Approximately 70% of the patients admitted to the hospital with an acute myocardial infarction have type 2 diabetes mellitus or impaired glucose tolerance (IGT). Insulin resistance with compensatory hyperinsulinemia is a feature that is common to both type 2 diabetes and IGT. Increased risk of coronary heart disease (CHD) in conditions characterized by insulin resistance has been associated with hyperinsulinemia and hyperproinsulinemia. As indicated in several studies, there exists a connection between postprandial hyperinsulinemia/hyperglycemia and activation of the coagulation cascade. The recent finding that tissue factor (TF) is produced and secreted by the alpha and beta cells of the islets of Langerhans maybe the link between these 2 conditions. The local production of TF in human islets and excretion of microparticle-bound or alternatively spliced soluble TF in response to prolonged periods of hyperglycemia provide a tentative explanation for the activation of the TF pathway during hyperinsulinemia. Here we review the field and set forth a hypothesis that links TF expression in the islets of Langerhans to the increased risk of CHD.