Obesity, one of the most prevalent and pressing global health challenges, has significant implications for cardiovascular disease (CVD) morbidity and mortality. Diagnostic testing for CVD is substantially affected by obesity, which affects test selection and execution and complicates the interpretation of diagnostic testing. Structural and metabolic changes in individuals with obesity create both physiological alterations and technical limitations across diagnostic modalities, as obesity alters cardiovascular (CV) structure, function, and diagnostic test accuracy. This review explores the practical implications of obesity for CV diagnostics, including physical examination, electrocardiogram interpretation, echocardiography, nuclear stress imaging, computed tomography, positron emission tomography, coronary calcium scoring, and magnetic resonance imaging. Although each modality faces unique challenges in individuals with obesity, modern techniques, a systematic approach, and individualized protocols can greatly enhance test performance and diagnostic yield. This review aims to provide a comprehensive narrative within a practical framework for optimizing CV diagnostics in patients with obesity to optimize CV testing in this growing population. We deal in detail with each investigative modality, providing an overview of the specific considerations in patients with obesity, along with practical recommendations for test selection, application, and interpretation. With an organized and personalized approach, diagnostic testing for CVD can be greatly improved in this specific, rapidly growing, and clinically important population.
