Background Whether being metabolically healthy obese (MHO)-defined by the presence of obesity in the absence of metabolic syndrome-is associated with subsequent cardiovascular disease (CVD) remains unclear and may depend on the participants' age. We examined the association of being MHO with CVD risk in the elderly. Methods and Findings This study included 5,314 individuals (mean age 68 years) from the prospective population-based Rotterdam Study. We categorized our population in groups according to body mass index (BMI) and presence and absence of metabolic syndrome, and estimated the hazard ratio (HR) and 95% confidence interval (95% CI) for every group by using Cox proportional hazard models. Among 1048 (19.7%) obese individuals we identified 260 (24.8%) MHO subjects. Over 14 years of follow-up there were 861 incident CVD cases. In the multivariable adjusted analysis, we did not observe an increased CVD risk in MHO individuals (HR 1.07, 95%CI 0.75-1.53), compared to normal weight individuals without metabolic syndrome. CVD risk was increased by the presence of metabolic syndrome in normal weight (HR 1.35, 95%CI 1.02-1.80), overweight (HR 1.32, 95%CI 1.09-1.60) and obese (HR 1.33, 95%CI 1.07-1.66) individuals, compared to those with normal weight without metabolic syndrome. In a mediation analysis, 71.3% of the association between BMI and CVD was explained by the presence of metabolic syndrome. Conclusions In our elderly population, we found that the presence of obesity without metabolic syndrome did not confer a higher CVD risk. However, metabolic syndrome was strongly associated with CVD risk, and was associated with an increased risk in all BMI categories. Therefore, preventive interventions targeting cardiometabolic risk factors could be considered in elderly, regardless of weight status.