Beyond BMI: Rethinking Obesity Metrics and Cardiovascular Risk in the Era of Precision Medicine

Obesity remains a dominant risk factor for cardiovascular disease, yet its classification continues to rely heavily on body mass index (BMI)—a metric that fails to capture individual variability in fat distribution, metabolic health, and cardiometabolic risk. This narrative review analyzes 35 articles published between 2018 and 2025 to explore the limitations of BMI and outlines emerging strategies for obesity redefinition through a precision medicine lens. Drawing from recent advances in imaging, metabolomics, and genomic profiling, we highlight alternative metrics such as visceral adipose tissue (VAT), epicardial adipose tissue (EAT), waist-to-hip ratio (WHR), and multi-omic phenotyping that provide superior predictive value for cardiovascular outcomes. The review synthesizes data on metabolically healthy and unhealthy phenotypes, emphasizes the pathophysiological role of EAT in heart failure and arrhythmogenesis, and discusses the cardioprotective effects of pharmacologic agents such as glucagon-like peptide-1 (GLP-1) receptor agonists. Clinical implications include improved risk stratification, earlier disease detection, and individualized therapeutic targeting. Despite current barriers to widespread implementation—such as imaging cost, access to omics, and lack of guideline integration—this paradigm shift holds promise for refining cardiovascular prevention strategies. Redefining obesity using biologically informed, phenotype-based models is indispensable for aligning clinical practice with the complexities of modern cardiometabolic disease.