More than one-third of US adults currently fall under the category of obese subjects, with body mass index (BMI) >30 kg/m², as defined by the WHO,1 while severe or morbid obesity (BMI >35 kg/m²) is the fastest growing category of obesity. This extreme obesity category was also the specific target population of the interesting study by Shah et al2 in their Heart publication.

Echocardiography applied to obese patients can result in non-diagnostic images in up to 30% of patients3 and clinicians may reasonably choose to avoid stress echocardiography in this specific patient population, because of concerns that such a technically demanding test will be inconclusive, if feasible at all. This is where contrast during stress echocardiography comes in in clinical practice, not to withhold the many advantages of a bedside, widely available imaging provocative test in such prevalent obese population. An additional advantage is that contrast stress echocardiography does not expose subjects to non-ionising radiation, it has been demonstrated safe early in the chest pain unit4 and without potential long-term adverse effects also …