1. Myocardial insulin resistance and abnormal Ca(2+) regulation are hallmarks of hypertrophic and diabetic hearts, but deprivation of energetic substrates does not tell the whole story. Is there a link between the aetiology of these dysfunctions? 2. Diabetic cardiomyopathy is defined as phenotypic changes in the heart muscle cell independent of associated coronary vascular disease. The cellular consequences of diabetes on excitation-contraction (E-C) coupling and insulin signalling are presented in various models of diabetes in order to set the stage for exploring the pathogenesis of heart disease. 3. Excess glucose or fatty acids can lead to augmented flux through the hexosamine biosynthesis pathway (HBP). The formation of uridine 5 cent-diphosphate-hexosamines has been shown to be involved in abnormal E-C coupling and myocardial insulin resistance. 4. There is growing evidence that O-linked glycosylation (downstream of HBP) may regulate the function of cytosolic and nuclear proteins in a dynamic manner, similar to phosphorylation and perhaps involving reciprocal or synergistic modification of serine/threonine sites. 5. This review focuses on the question of whether there is a role for HBP and dynamic O-linked glycosylation in the development of myocardial insulin resistance and abnormal E-C coupling. The emerging concept that O-linked glycosylation is a regulatory, post-translational modification of cytosolic/nuclear proteins that interacts with phosphorylation in the heart is explored.