Traditionally, serum uric acid (SUA) has been implicated in acute gouty arthritis or chronic gouty arthropathy. However, SUA also plays a role in other pathological conditions especially in cardiovascular (CV), metabolic and renal disease. This narrative review considers the significant associations of SUA with kidney function, several CV risk factors and vascular diseases, supporting the concept of assessing hyperuricaemia for reasons other than just gout. Several drugs that reduce CV risk also decrease SUA levels, further improving vascular risk. Therefore, selecting SUA-lowering drugs to treat high-risk patients may prove beneficial in terms of reducing CV risk.