In Reply Sperry et al raise important discussion points pertaining to our multicenter study of technetium Tc 99m pyrophosphate cardiac imaging for diagnosis and prognosis of cardiac transthyretin amyloidosis (ATTR).¹ Our colleagues note that bone abnormalities in the ribs of elderly patients with osteoporosis may pose a technical complication in the calculation of the heart-to-contralateral (H/CL) ratio when using planar imaging. Indeed, it is not uncommon to encounter bony pathology, such as osteoporotic rib fractures or metastatic bone lesions, in planar imaging of the chest. In our practice, when such hot spots are encountered, we avoid them by adjusting the size and location of the circular region of interest. As long as the regions of interest drawn over the heart and contralateral chest remain equal in size and within the chest cavity for each individual patient, bony pathology can usually be avoided, protecting the integrity of the H/CL ratio.