Ischemic heart disease stands as the primary cause of mortality among diabetic patients. Despite advancements in vascular reconstruction and thrombolytic therapy that restore myocardial blood flow, these patients often experience poor cardiac function recovery and a higher mortality rate. This makes myocardial ischemia/reperfusion (I/R) injury a significant therapeutic challenge. Research indicates that, under diabetic or obese conditions, adipocytes release extracellular vesicles (EVs) containing a variety of biomolecules, including RNA, proteins, adipocytokines, and mitochondria. These EVs play a pivotal role in maintaining systemic metabolic homeostasis. Importantly, adipocyte-derived EVs facilitate communication with diabetic hearts and play a regulatory role in myocardial I/R injury. This review summarizes recent studies on the modulatory effects of adipocyte-derived EVs on diabetic myocardial I/R injury, highlighting potential underlying mechanisms.