What are the issues regarding starting clozapine in a patient with structural heart disease, such as cardiomyopathy or cardiac valve disease?

There are no evidence-based guidelines for starting clozapine in patients with structural heart disease, such as cardiomyopathy or cardiac valve disease. If the benefit of clozapine outweighs the potential risks, the clinician may consider clozapine in consultation with a cardiologist, after a complete cardiac evaluation, and under close monitoring. Starting such patients requires liaison with cardiology for expert opinion and close monitoring for evidence of cardiac problems. A monitoring regime has been proposed for starting clozapine in patients with structural heart disease (Sanchez et al, Br J Psych Open 2016). This includes, at baseline: temperature, C-reactive protein, troponin, EKG, and transthoracic echocardiography. Daily: temperature, and heart rate. Twenty-four hours after a dose increase: C-reactive protein, troponin, and EKG. In the event of fever or abnormal C-reactive protein/troponin: temperature, CRP, troponin, EKG, and transthoracic echocardiography. Six weeks after the final dose increase: temperature, C-reactive protein, troponin, EKG, and transthoracic echocardiography. Interpretation of findings should be done in collaboration with cardiology.

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