The obesity epidemic is a global public health concern that increases the likelihood of morbidity and mortality of metabolic and cardiovascular disease (CVD), and threatens to reduce life expectancy around the world. The concept of the metabolic syndrome (MetS) takes into account the essential role that visceral fat plays in the development of metabolic and CVDs, and indicates how waist circumference measurement aids patient identification in the clinical setting. However, MetS cannot be used to assess global CVD risk and is, at best, another modifiable risk factor. Thus, the global cardiometabolic risk (ie, global risk of CVD resulting from traditional risk factors combined with the additional contribution of MetS) should be considered individually. The contribution of abdominal obesity to global cardiometabolic risk is reviewed and also discussed are potential underlying mechanisms including adipocytokine, insulin resistance, lipotoxicity and ectopic fat deposition in the heart components: (1) circulatory and locally recruited fat, (2) intra-and extra-myocellular fat, (3) perivascular fat, and (4) pericardial fat.