NPPB and obesity due to melanocortin 4 receptor deficiency: HFO is likely to develop by age 30 with a BMI >70 kg/m2 and by age 50 in asymptomatic obese individuals with a BMI of 50 kg/m2 [4]. Clinical diagnosis of HFO is challenging since HF symptoms can be attributed to deconditioning resulting from obesity, the elevation of brain natriuretic peptide (BNP) is blunted, and weight limits cardiac catheterization and evaluation by echocardiography [24].