There are no evidence-based guidelines for starting clozapine in patients with structural heart disease, such as cardiac valve disease or cardiomyopathy. With regard to cardiac valve disease, there is little or no literature on this topic, though little clear reason for additional concern in the absence of other cardiac abnormalities. With regard to other structural heart disease, such as cardiomyopathy, 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 that might develop early in treatment (e.g., myocarditis), and for any indications of worsening heart function (e.g., reduction in ejection fraction). 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. There needs to be careful and ongoing evaluation for any changes in cardiac function based on routine follow-up with a cardiologist. The cardiologist determines to what extent echocardiography or other testing is needed.