One of the biggest impacts on resource consumption for Azure SQL DB are repeated data pulls by the application layer. No matter how fast those queries execute calling the same procedure or issuing the same SQL statements hundreds, thousands, or million times a day can wreak havoc on database performance. Death by a thousand cuts can easily bring a system to its knees. Sometimes it’s hard for DBAs to troubleshoot these actively as the execution of the statements happens so quickly they don’t even show in tools like sp_whoisactive. It’s not until you begin to dive into things like Query Performance Insights or Query Store that you start to see the real issue.