Faculty Spotlight: Pooja Prasad, MD

 

Pinpointing Diagnosis and Tailoring Treatment

“Advanced heart failure is the perfect fit for me,” said Pooja Prasad, MD. “With patients at different stages of their disease process and a broad range of therapies available, we have to think critically about our patients’ pathophysiology, prognosis and trajectory. Their psychosocial status and support systems are key to their success with advanced therapies, and what is especially rewarding is working with our multidisciplinary team to help patients with barriers in these areas overcome them.”

Born in Oklahoma City, Dr. Prasad grew up in Morgan Hill, south of San Jose. While earning bachelor’s degrees from Wellesley College in biological sciences and peace and justice studies with a concentration in women’s health, she became interested in the social determinants of health. “It was eye-opening to think about how a patient’s ZIP code, race or gender could impact their lifespan and health outcomes,” she said. “I thought that as a physician, I could take a patient-centered approach to addressing the biological and psychosocial determinants of our health.”

She earned her medical degree from the University of Rochester School of Medicine, then completed her internal medicine residency at UC Davis, her general cardiology fellowship at Oregon Health & Science University, and her advanced heart failure and transplant cardiology fellowship at UCSF.

One memorable experience she had as an advanced fellow was caring for a patient who was an immigrant and did not have family nearby. “One of the requirements to be a candidate for heart transplant is having a 24-hour caregiver who can live near San Francisco for six weeks,” said Dr. Prasad. “He didn’t have anyone who could do that for him, but there’s a strong sense of community in his culture. A friend of his put the word out to his own network, and the patient was able to secure a caregiver for the post-transplant period. It was amazing to see how his community stepped up for him. It also taught me to persevere – to be transparent with the patient about obstacles, and at the same time to be their advocate.”

Improving Treatment of Cardiac Amyloidosis

One of her research and clinical mentors at Oregon Health & Science University was Ahmad Masri, MD, MS, an expert in cardiomyopathies and cardiac imaging. Dr. Prasad worked with him on a research project focused on cardiac amyloidosis, a rare condition which develops when the transthyretin protein folds abnormally and is deposited in the heart tissue. The misfolded protein infiltrates the heart and makes it stiffer. This can be one cause of heart failure with preserved ejection fraction (HFpEF), in which the heart muscle is able to squeeze normally, but has difficulty relaxing fully so it can fill with blood for the next contraction. Amyloidosis can also affect other parts of the body such as the kidney and nervous system.

“It was helpful having a mentor at an early stage in my career who emphasized the importance of a thorough diagnostic evaluation for patients with left ventricular hypertrophy,” said Dr. Prasad. “Although HFpEF due to hypertension is very common, we wouldn’t want to miss amyloid. It’s important to get the diagnosis right so we can get patients on the correct therapy and help them feel better and live longer.”

Those therapies now include stabilizers, which help prevent the transthyretin protein from misfolding, as well as a silencer therapy which reduces production of transthyretin. “This is an exciting time, because we used to only have limited options, but now we have more than one,” said Dr. Prasad. “We have a new dilemma about what combination of drugs we should use, because we don’t yet have randomized clinical trials directly comparing the efficacy of these different options, or pinpointing which patients might do better with which therapies.”

Cardiologists are now able to detect cardiac amyloidosis earlier in the course of disease, allowing more timely intervention and potentially improving prognosis compared with previous patient cohorts who were diagnosed at more advanced stages of disease. Dr. Prasad enjoys collaborating on the care of patients with cardiac amyloidosis with her prior associate program director and now colleague Mandar Aras, MD, PhD, co-director of the UCSF Comprehensive Amyloidosis Program.

Dr. Prasad is conducting research to help determine the best ways to screen patients for cardiac amyloidosis. She was recently awarded a 2025 Women as One mentorship award, in which she will work with Hanna Gaggin, MD, MPH, a cardiologist at Massachusetts General Hospital, to study sex disparities in the diagnosis of amyloidosis. “Women are diagnosed at a later stage than men, which is not good for prognosis, since treatment works better when initiated early on in the disease process,” said Dr. Prasad. “We hypothesize that a lot of the red flags we look for to test for amyloid are tailored to men, which results in underdiagnosis in women.”

Customizing Treatment of Pulmonary Hypertension

Having received training in pulmonary hypertension during her advanced heart failure fellowship, Dr. Prasad also provides care to patients in the UCSF Pulmonary Hypertension Clinic with a variety of disease processes. Pulmonary hypertension is a disease characterized by high blood pressure in the lungs, and affects many patients who also have HFpEF. Pulmonary hypertension actually has five different subtypes, each with its own pathophysiology; only some subtypes have effective therapeutics.

“What’s tricky is that classically, when we think about pulmonary hypertension, we think about Group 1, in which the pulmonary arteries are directly affected,” said Dr. Prasad, referencing the blood vessels that carry deoxygenated blood from the heart to the lungs to pick up oxygen and unload carbon dioxide. “But the truth is that the most common type of pulmonary hypertension, Group 2, results from disease in the left side of the heart and long-term congestion resulting in pulmonary vascular remodeling.”

Dr. Prasad is the UCSF lead for an international, multisite randomized controlled trial of a new drug developed by Tectonic Therapeutic to help patients with pulmonary hypertension caused by HFpEF. Its development was inspired by a naturally occurring hormone called relaxin, which has been shown to be upregulated in pregnant women. “We know that with pregnancy, there is physiologic vasodilation to accommodate for increased blood flow from the placenta,” she said. “This is a mimetic of that naturally produced hormone, and we want to determine if it could help patients improve their exercise capacity and hemodynamics.

“Patients with pulmonary hypertension secondary to HFpEF have a higher risk of death compared with patients with HFpEF but without pulmonary hypertension,” said Dr. Prasad. “Not everyone with HFpEF gets pulmonary hypertension. We hope to be able to target that pulmonary hypertension specifically, given that at the moment there are no therapies specifically treating this elevation in pulmonary artery pressure.”

Dr. Prasad takes a very thorough approach to patients’ care, working to make a granular diagnosis that identifies not only their cardiac condition, but also its origin and subtype so she can tailor an effective treatment plan. She also leverages the appropriate diagnostics and resources to best manage their condition and maximize quality of life, whether it is sleep apnea testing, obesity management, or supervised exercise programs.

“I’m a big fan of pulmonary rehabilitation and cardiac rehabilitation programs,” said Dr. Prasad. “A lot of times patients’ primary complaint is trouble breathing when they exercise, so it can be very helpful getting guidance on how much they can push themselves, especially if they have a new diagnosis and are still adjusting to their medical condition.” 

She enjoys partnering with members of her team, including nurses, nurse practitioners, social workers and psychiatrists, to help patients access the resources they need. “Sometimes we have to be creative,” said Dr. Prasad. “For example, cardiac rehabilitation is not covered by insurance for patients with HFpEF, even though we know it’s a helpful tool. But sometimes we can get them into pulmonary rehab if they have another qualifying diagnosis, such as COPD. A lot of it is about knowing the system and working with colleagues. I’m very grateful to have a wonderful support staff who are both hard working and experienced.”

Heart Transplantation and the Art of Medicine

In addition to caring for patients with pulmonary hypertension, heart failure and cardiac amyloidosis, Dr. Prasad also cares for advanced heart failure patients before, during and after receiving a heart transplant or a pump such as a left ventricular assist device (LVAD).

Determining the right timing for recommending these advanced therapies is key. “Even if patients have the same disease process, it’s important to think about each patient’s prognosis and risk profile,” said Dr. Prasad.

“It’s important to prognosticate patients as quickly and accurately as possible using the tools we need, whether it’s a right heart catheterization or a cardiopulmonary exercise test – where we exercise patients and measure oxygen consumption, carbon dioxide production, ventilatory responses and blood pressure and heart rate response to exercise,” said Dr. Prasad. “This gives us an idea of how well their circulatory system is delivering oxygen to their organs, and what stage of disease our patients are at.”

Because transplant is a high-risk procedure and requires patients to take immunosuppressant drugs for life, which carry significant side effects, it’s important to evaluate the patient when the benefits of transplant outweigh the risks. “We want to make sure we’ve optimized everything we can before we decide to move forward with heart transplantation,” said Dr. Prasad.

One of the biggest risks of heart transplant is rejection of the donor organ. While immunosuppressants can lower this risk, they also leave the transplant recipient more vulnerable to infections, which can be life-threatening. She is excited about recent advances in post-transplant care, including non-invasive methods to detect rejection. Donor-derived cell-free DNA is a blood test that indicates possible injury to the donated organ, including a rejection episode.  

“This has helped us really improve care for transplant patients, because it allows us to do heart biopsies less frequently,” said Dr. Prasad. “If this test is normal, we can be very confident that the patient is not rejecting their organ. But if it’s even mildly elevated, we need to perform a biopsy to check for rejection. Donor-derived cell-free DNA allows us to apply a precision medicine approach to patients post-transplant. Each patient’s likelihood to reject a heart or to get an infection is different, and in patients who receive another transplanted organ in addition to a donor heart, interpreting this test is challenging. Balancing the risk of rejection and infection in a post-transplant patient requires nuance and is a perfect example of the ‘art of medicine.’”

Early Diagnosis of Cardiac Allograft Vasculopathy 

Dr. Prasad also has a special interest in cardiac allograft vasculopathy (CAV), a disease characterized by thickening of the walls of the arteries supplying blood to the transplanted heart. When at Oregon Health & Science University, she investigated the role of vasodilator stress echo in diagnosis of CAV. CAV is one of the leading long-term causes of death in heart transplant recipients, and can also be a reason to pursue a second heart transplant.

“CAV leads to narrowing of the arteries of the donor heart, but it’s not as simple as run-of-the-mill coronary artery disease,” said Dr. Prasad. “It’s actually both an immune and non-immune mediated process.” In addition to classic risk factors for coronary artery disease, rejection episodes – in which a patient’s immune system identifies the heart as “not self” and attacks the blood vessels within the donor heart – are implicated in this process.

Part of the challenge of diagnosing this disease is that it does not always affect the large arteries, which can be seen on an angiogram, but rather the microvasculature, or the smaller blood vessels within the heart. However, advanced cardiac imaging modalities now available at UCSF, such as myocardial perfusion positron emission tomography (PET) stress test and magnetic resonance imaging (MRI) with perfusion, allow cardiologists to better measure blood flow throughout the heart. “It’s exciting to have advanced non-invasive imaging at our fingertips, so we can appropriately tailor immunosuppressants in our patients and prevent progression of CAV,” said Dr. Prasad.

The Joys of Being a Clinician-Educator

In addition to her care of patients and clinical research, Dr. Prasad enjoys serving as one of the inaugural fellowship coaches in the coaching program that started in 2025. “I have enjoyed informal coaching and guiding trainees through the uncertainty and decisions they face when mapping out their career,” she said. “Because I recently experienced these questions myself, I look forward to being an active listener and guiding fellows in a more formal capacity. It’s very rewarding to be part of their journey.”

Dr. Prasad is passionate about educating trainees. From serving as a preceptor for medical students to working with internal medicine residents and heart failure fellows in the hospital and clinic, she interfaces with trainees at a variety of stages of their training. She teaches her trainees to approach diagnosis with the utmost detail. “It’s important to keep a broad differential diagnosis for whatever cardiac problem you’re faced with in a consultation,” said Dr. Prasad. “Pay attention to the diagnostics, be extremely detail-oriented and thorough, and don’t assume you know what’s causing something.”

While the idea of “Occam’s razor” sounds appealing, in which the simplest, most elegant explanation is the one closest to the truth, Dr. Prasad notes that the reality of medicine is messier. “Patients are very complex,” she said. “As they get older, they have more comorbidities, such as kidney, liver and lung disease. It’s important to think about how different aspects of a patient’s health come together and play a role in what we’re seeing. Trying to synthesize that is the art and challenge of this job. That’s why we train in internal medicine before becoming cardiologists. We can’t think only about the heart.”

As a prior advanced fellow and now faculty member at UCSF, Dr. Prasad appreciates working with and learning from her colleagues. “Each team member is an expert in their area, and we’re so lucky to have them as our partners,” she said. “I have fond memories of being an early heart failure fellow and running the transplant lab reviews. The transplant coordinators have so much experience, and I learned a lot from them as they gently directed me. Similarly, I’ve learned so much about LVAD management from our high skilled and specialized Mechanical Circulatory Support (MCS) team.”

She also values UCSF’s commitment to providing care to patients from diverse backgrounds. “I’ve had the opportunity to care for patients who live all over California as well as Nevada,” said Dr. Prasad. “They come from diverse ethnic, cultural and socioeconomic backgrounds. At UCSF, our practice is to do our very best to not let insurance or a patient’s socioeconomic status prevent us from utilizing advanced therapies. We work together as a team to help patients overcome those challenges.” 

“Dr. Prasad joined us after graduating from the Advanced Heart Failure and Transplant Cardiology fellowship training at UCSF,” said Liviu Klein, MD, MS, medical director of the Advanced Heart Failure Comprehensive Care Center. “Dr. Prasad is highly regarded by her colleagues and loved by her patients for her kindness and exceptional bedside manner. In the Advanced Heart Failure Comprehensive Care Center, she will lead the new initiative of caring for patients with HFpEF, a growing area of need.”

Outside of medicine, Dr. Prasad enjoys Orangetheory workouts, hiking, a good scone followed by a stroll in the Japanese Garden, and traveling the world with friends and family.

-  Elizabeth Chur