Assessment of body fat distribution, particularly visceral adipose tissue, may be important for accurate risk evaluation for cardiovascular disease in the elderly. This 1997-1998 US study examined the association of incident myocardial infarction (MI) with total adiposity (body mass index and fat mass) and body fat distribution (waist-to-thigh ratio, waist circumference, visceral and subcutaneous adipose tissue) in well-functioning men (n = 1,116) and women (n = 1,387) aged 70-79 years enrolled in the Health, Aging and Body Composition Study. There were 116 MI events (71 in men, 45 in women) during an average follow-up time of 4.6 (standard deviation, 0.9) years. No association was found between incident MI and the adiposity or fat distribution variables for men. For women, visceral adipose tissue was an independent predictor of MI (hazard ratio = 1.67, 95% confidence interval: 1.28, 2.17 per standard-deviation increase; p < 0.001). No association was found between body mass index or total fat mass and MI events in women. The association of visceral adipose tissue with MI in women was independent of high density lipoprotein cholesterol, interleukin-6 concentration, hypertension, and diabetes (hazard ratio = 1.79, 95% confidence interval: 1.24, 2.58 per standard-deviation increase; p < 0.01). The amount of adipose tissue stored in the intraabdominal cavity is an important, independent risk factor for MI in well-functioning, elderly women.