Childhood obesity is a growing public health issue. Fat distribution is an important factor, with mounting evidence that visceral adiposity is associated with the development of cardiovascular changes and diseases. Epicardial adipose tissue is a visceral fat depot associated with metabolic syndrome and coronary artery disease in adults. We report the results of a cross-sectional study including 48 obese and lean adolescents, showing a strong and significant correlation between epicardial adipose tissue volume measured by MRI and central adiposity parameters as well as cardiovascular risk factors. Moreover, epicardial fat volume is higher in obese adolescents with metabolic syndrome than in obese adolescents without metabolic syndrome. Therefore, early assessment of epicardial adipose tissue volume may help identify adolescents at increased risk of future cardiometabolic disease.