We congratulate Dippe et al. for their work that addressed the role of myocardial scintigraphy in the diagnosis of myocardial ischemia in obese patients. Despite limitations, body mass index (BMI) has been the most used anthropometric tool for assessing nutritional status in adults. Epidemiologic studies have identified high BMI as a risk factor for an expanding set of chronic diseases, including cardiovascular disease and diabetes mellitus. The Global Burden of Disease (GBD) Obesity Collaborators found that excess body weight accounted for about 4 million deaths in 2015. Nearly 70% of these deaths were due to cardiovascular disease, and more than 60% of them occurred among obese persons (BMI ≥ 30 Kg/m²). The use of a database of consecutive patients provides a sample of obese patients from the real-world scenario and portrays the current clinical practice in which the cardiologist faces major diagnostic challenges in obese patients. All diagnostic methods have significant challenges in obese patients such as the limitation of the acoustic window in the echocardiogram, higher incidence of photon attenuation on computed tomography and myocardial scintigraphy and bore size limitations to cardiac resonance imaging. Radiation-sparing techniques are more difficult to use in heavier patients. The finding that clinical data such as the presence of diabetes mellitus, older age and typical symptoms of angina highlights the need of careful clinical evaluation in order to adequate request ischemic screening tests in patients with suspected coronary artery disease, especially in the obese. Another important finding of their study was the absence of association between obesity alone, especially in the group with BMI greater than 40, with the presence of ischemia. A technical aspect that was not clear in the article and whether the authors used the prone acquisition when there was doubt about the presence of breast attenuation and also the technique used to quantify the visual or automatic ischemia.

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