Although the epidemic of atherosclerosis has slowed down in industrialized nations, it has increased in speed and severity in developing countries. The worldwide expanding incidence and prevalence of obesity, insulin resistance, and diabetes mellitus may be among the most important drivers of this trend, and the role of visceral adipose tissue as a promoter of atherosclerosis has come under intense scrutiny. Epicardial adipose tissue (EAT) is embryologically similar to the visceral fat in the intraperitoneal space. Both adipose compartments are capable of secreting numerous pro-atherosclerotic cytokines and have been shown to promote inflammation in patients with dysmetabolic syndromes and in patients with established coronary artery disease. The adverse cardiovascular effects of EAT extend to influencing the development of atrial fibrillation and heart failure, mostly with preserved ejection fraction, through a combination of inflammatory, pro-fibrotic, and pro-arrhythmogenic pathways. In this work we provide an overview of the current understanding of the role of EAT in the development of several cardiovascular conditions as well as some of the therapeutic advances in the field.