Cardiogenic shock cost-effectiveness of therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2] James Nasr[3]
Cardiogenic shock cost-effectiveness of therapy
Overview
Cardiogenic shock is associated with substantial health care costs because of high-acuity hospitalization, intensive care unit care, invasive coronary procedures, vasoactive therapy, temporary mechanical circulatory support, device-related complications, rehabilitation, readmissions, and post-discharge long-term care. The cost-effectiveness evidence base is limited compared with the clinical trial evidence base; most data are derived from trial subanalyses, administrative databases, observational cohorts, and economic modeling studies.[1][2]
Cost-effectiveness should be interpreted in relation to patient selection, shock phenotype, expected survival, neurologic prognosis, device complications, institutional expertise, discharge destination, quality of life, and post-discharge resource use. High cost alone does not establish poor value; value depends on whether the intervention improves survival or quality-adjusted survival in the population treated.
Economic burden of cardiogenic shock
Hospitalization costs for cardiogenic shock vary by country, etiology, device use, complications, survival status, and discharge destination.
| Study or population | Cost findings | Clinical interpretation |
|---|---|---|
| STEMI complicated by cardiogenic shock in the United States | Mean total hospital costs were reported as $41,774 ± $45,252, with median ICU length of stay of 6 days and mean hospital length of stay of 8.9 ± 11.8 days. | Index hospitalization costs are substantial even before accounting for post-discharge care.[1] |
| National Inpatient Sample AMI-CS admissions, 2000-2014 | Among 444,253 AMI-CS admissions over the study period, multiorgan system failure increased resource utilization approximately 4.3-fold. | The aggregate economic burden of AMI-CS in the United States is substantial, though precise annual estimates vary by data source and methodology.[3] |
| Ontario AMI-CS cohort, 2009-2019 | Median total 1-year cost was $37,913. Among patients who survived to discharge, median total cost was $45,713, with $12,719 accumulated after discharge. | Post-discharge care represented approximately 28% of 1-year cost among survivors, emphasizing the economic importance of rehabilitation, readmission prevention, and survivorship care.[2] |
| Ontario AMI-CS survivors readmitted within 1 year | Among the 33.1% of survivors readmitted within 1 year, median total cost was $63,539. | Readmissions are a major contributor to total cost and are a key target for cost-effective secondary prevention.[2] |
| Japan nationwide AMI-CS analysis, 2012-2023 | Average costs were $26,300 for survivors treated with mechanical circulatory support versus $13,600 for survivors without mechanical circulatory support. | Device use increases short-term cost; value depends on patient selection and clinical benefit.[4] |
| VA-ECMO for cardiogenic shock in the United States | Median inpatient costs were reported as $320,269 for ECMO alone and $390,508 for ECMO plus left ventricular mechanical unloading. | VA-ECMO is among the highest-cost therapies; routine use without demonstrated survival benefit is unlikely to be economically favorable.[5] |
Early revascularization
Emergency revascularization is the most strongly supported therapy in acute myocardial infarction-related cardiogenic shock from both clinical and economic perspectives. The SHOCK trial demonstrated improved survival with early revascularization compared with initial medical stabilization in acute myocardial infarction complicated by cardiogenic shock. The 6-month mortality absolute risk reduction was 12.8% (50.3% vs 63.1%; P=0.027), corresponding to a number needed to treat of approximately 8 to save one life.[6][7]
An economic substudy of the SHOCK trial found that early revascularization was associated with higher initial hospitalization costs but improved 1-year survival, with an estimated cost per life-year saved within conventionally accepted thresholds. Combined with the magnitude and durability of survival benefit through long-term follow-up, emergency revascularization is a high-value intervention in eligible patients.[8]
Culprit-only versus immediate multivessel PCI
In the CULPRIT-SHOCK trial, culprit-lesion-only PCI reduced the composite of death or renal replacement therapy compared with immediate multivessel PCI in patients with acute myocardial infarction-related cardiogenic shock and multivessel coronary artery disease. The primary endpoint occurred in 45.9% of the culprit-only group and 55.4% of the immediate multivessel PCI group (RR 0.83; 95% CI 0.71-0.96).[9]
Culprit-lesion-only PCI is likely economically favorable compared with routine immediate multivessel PCI because it reduces procedural complexity and contrast exposure while improving the 30-day composite endpoint. However, the 1-year follow-up of CULPRIT-SHOCK showed attenuation of the mortality difference (50.0% vs 56.9%; RR 0.88; 95% CI 0.76-1.01; P=0.07), and a formal cost-effectiveness analysis specific to CULPRIT-SHOCK has not been published. Therefore, this should be described as likely higher value rather than proven cost-effective.[10]
Temporary mechanical circulatory support
Intra-aortic balloon pump
The IABP-SHOCK II trial found no mortality benefit from routine intra-aortic balloon pump use in acute myocardial infarction-related cardiogenic shock. Costs were similar between the IABP and control groups (€33,155 vs €32,538).[1]
Because routine IABP adds device-related cost without demonstrated survival benefit in AMI-CS, routine IABP use is not economically supported. IABP may still have selected roles in specific physiologic or procedural contexts, but routine use should not be considered cost-effective.
Microaxial flow pumps
Cost-effectiveness data for Impella and other microaxial flow pumps are evolving and depend heavily on patient selection.
An early European modeling study cited by the 2015 SCAI/ACC/HFSA/STS consensus statement estimated an incremental cost-effectiveness ratio of approximately €31,727-€38,069 per QALY for Impella compared with IABP, within conventionally accepted cost-effectiveness thresholds.[11] However, this model predated both IABP-SHOCK II, which showed no mortality benefit for IABP, and DanGer Shock, and was based on limited clinical data. The clinical assumptions underlying this estimate have been substantially challenged by subsequent evidence.
In contrast, a 2022 propensity-matched cohort study of 817 matched pairs found that Impella use in AMI-CS was associated with higher mortality and higher mean costs compared with IABP. Mean costs were higher by $51,680 at 30 days and $46,609 at 1 year.[12] This observational analysis predated DanGer Shock and likely included broader, less selected populations.
The DanGer Shock trial showed that Impella CP reduced 180-day all-cause mortality in selected patients with STEMI-related cardiogenic shock without anoxic brain injury (45.8% vs 58.5%; HR 0.74; 95% CI 0.55-0.99), but increased bleeding, limb ischemia, and renal replacement therapy.[13][14]
A formal cost-effectiveness analysis of DanGer Shock was not provided in the supplied evidence base. The mortality reduction suggests potential cost-effectiveness in the selected population studied, but device cost, complication cost, center expertise, and generalizability remain unresolved.
VA-ECMO
Routine VA-ECMO in AMI-related cardiogenic shock is unlikely to be cost-effective because randomized data have not shown mortality benefit and the intervention carries high hospitalization cost and complication burden. ECLS-SHOCK found no reduction in 30-day mortality with routine early VA-ECMO in infarct-related cardiogenic shock, while bleeding and peripheral vascular complications were increased.[15]
A Taiwanese risk-stratification analysis suggested that ECMO cost-effectiveness varies by predicted mortality risk and becomes progressively less favorable as predicted mortality rises above approximately 68%.[16]
ECPELLA and left ventricular unloading during VA-ECMO
The combination of VA-ECMO plus Impella, often termed ECPELLA, may improve LV unloading but increases device complexity and cost. A meta-analysis of observational studies found lower short-term mortality with ECPELLA compared with VA-ECMO alone (RR 0.89; 95% CI 0.80-0.99), but higher rates of hemolysis, limb ischemia, and renal replacement therapy.[17]
In a US cost analysis, ECMO plus left ventricular mechanical unloading had higher median total inpatient cost than ECMO alone ($390,508 vs $320,269).[5] No formal cost-effectiveness analysis of ECPELLA was provided in the supplied evidence base.
Shock teams
Multidisciplinary shock teams may improve both outcomes and value by accelerating diagnosis, invasive hemodynamic assessment, revascularization, device selection, transfer decisions, and de-escalation or exit strategy planning.
A single-center cost-effectiveness analysis of 244 patients with refractory cardiogenic shock found that a shock team approach improved survival at discharge (61.0% vs 47.9%) and at 1 year (55.0% vs 40.5%) compared with standard care. The incremental cost-effectiveness ratio was $102,088 per additional survivor at discharge, $96,152 per additional survivor at 1 year, and $127,862 per QALY gained. At a willingness-to-pay threshold of $150,000 per QALY, the shock team approach was cost-effective in most simulations and dominant in nearly one-third of simulations.[18]
A multicenter observational analysis of more than 1,200 cardiogenic shock admissions found that centers with shock teams had lower adjusted odds of cardiac intensive care unit mortality and shorter cardiac intensive care unit length of stay.[19]
Pulmonary artery catheter-guided management
Invasive hemodynamic monitoring with a pulmonary artery catheter may improve value by guiding vasoactive therapy, volume management, phenotyping, and mechanical circulatory support decision-making. Although no randomized trial has evaluated pulmonary artery catheter cost-effectiveness specifically in cardiogenic shock, observational data suggest that pulmonary artery catheter use is associated with improved survival and may reduce unnecessary mechanical circulatory support escalation, which has direct cost implications. The 2025 ACC Expert Consensus Statement supports pulmonary artery catheter use in cardiogenic shock management.[20]
Regionalized cardiogenic shock care
Regionalized cardiogenic shock systems and hub-and-spoke transfer models may improve value by concentrating expertise, increasing access to shock teams, improving appropriate device selection, and facilitating early transfer for advanced therapies. The 2025 ACC Expert Consensus Statement and contemporary reviews support standardized interdisciplinary care and regional coordination, although formal cost-effectiveness analyses of regionalized cardiogenic shock networks remain limited.[20][21]
Cardiac rehabilitation
Cardiac rehabilitation is one of the most consistently cost-effective post-acute cardiovascular interventions and should be included in the economic assessment of cardiogenic shock survivorship. The 2025 acute coronary syndromes guideline gives referral to outpatient cardiac rehabilitation before hospital discharge a class 1, level A recommendation for patients with ACS.[14]
A systematic review found incremental cost-effectiveness ratios ranging from $1,065 to $71,755 per QALY for cardiac rehabilitation compared with no cardiac rehabilitation, with most studies concluding that cardiac rehabilitation was cost-effective.[22]
In Medicare beneficiaries aged 65 years and older with coronary heart disease, cardiac rehabilitation had an estimated incremental cost-effectiveness ratio of $30,188 per QALY over remaining lifetimes.[23]
The 2024 Cochrane review of exercise-based cardiac rehabilitation for heart failure found an 89.9% probability that cardiac rehabilitation was more cost-effective than usual care at a willingness-to-pay threshold of $50,000 per QALY, supporting its value in heart failure populations including cardiogenic shock survivors with residual ventricular dysfunction.[24]
For cardiogenic shock survivors, cardiac rehabilitation may be especially valuable because post-discharge costs and readmissions are major contributors to total 1-year cost. However, direct cost-effectiveness studies specifically in cardiogenic shock survivors are limited.
Clinically actionable economic approach
| Intervention | Economic interpretation | Practical implication |
|---|---|---|
| Early revascularization in AMI-CS | Strong clinical benefit; NNT approximately 8; published economic substudy supports favorable value | Do not delay eligible patients for cost reasons.[6] |
| Culprit-lesion-only PCI in AMI-CS with multivessel disease | Likely higher value than routine immediate multivessel PCI because 30-day composite outcomes are better and procedural complexity is lower, although 1-year mortality difference attenuates | Prefer culprit-lesion-only PCI with staged revascularization when appropriate.[9][10] |
| Routine IABP in AMI-CS | Similar costs with no mortality benefit | Avoid routine use; reserve for selected indications. |
| Impella CP in selected STEMI-CS | Mortality benefit shown in DanGer Shock; formal cost-effectiveness analysis pending | Consider in populations resembling DanGer Shock when expertise and complication management are available.[13] |
| Routine VA-ECMO in AMI-CS | Very high cost and no RCT-demonstrated mortality benefit | Avoid routine use; reserve for selected phenotypes and clear exit strategies.[15] |
| ECPELLA | Higher costs and higher complication rates; possible observational survival signal | Use selectively; formal cost-effectiveness is unknown.[17] |
| Shock team | Cost-effective at conventional willingness-to-pay thresholds in available single-center analysis | Implement standardized multidisciplinary shock team protocols where feasible.[18] |
| Pulmonary artery catheter-guided management | Formal cost-effectiveness data are limited; may improve value by guiding phenotype-specific therapy and avoiding unnecessary escalation | Use to guide complex shock management and device decisions when appropriate.[20] |
| Cardiac rehabilitation | Consistently cost-effective in coronary disease and heart failure populations | Refer eligible cardiogenic shock survivors before discharge.[22][24] |
Areas of uncertainty
- Formal cost-effectiveness analysis of DanGer Shock has not yet been provided in the supplied evidence base.
- Cost-effectiveness of temporary mechanical circulatory support in heart failure-related cardiogenic shock is poorly characterized.
- The generalizability of shock-team cost-effectiveness beyond tertiary centers is uncertain.
- ECPELLA cost-effectiveness is unknown despite increasing utilization.
- Cost-effectiveness of pulmonary artery catheter-guided management and regionalized cardiogenic shock networks requires further study.
- Long-term cost-effectiveness beyond 1 year is poorly characterized because survivors have high rates of readmission, disability, rehabilitation needs, and advanced heart failure therapy use.
- Regional cost variation is substantial, limiting direct transfer of economic estimates between the United States, Canada, Europe, and Asia.
- Quality-of-life and functional recovery data remain limited in cost-effectiveness models for cardiogenic shock therapies.
Common pitfalls
- Assuming that an expensive device is cost-effective because it improves hemodynamics
- Assuming that a low-cost therapy has good value despite lack of outcome benefit
- Using routine IABP or routine VA-ECMO in AMI-CS despite absence of randomized mortality benefit
- Applying DanGer Shock findings to unselected cardiogenic shock populations
- Ignoring post-discharge costs, which represent a substantial portion of 1-year costs among survivors
- Ignoring quality of life and functional recovery when interpreting QALY-based value
- Excluding cardiac rehabilitation because of frailty or deconditioning, despite strong cost-effectiveness evidence in high-risk cardiovascular populations
- Failing to implement shock teams because of perceived cost despite available cost-effectiveness data
- Interpreting observational device cost analyses as definitive causal evidence
References
- ↑ 1.0 1.1 1.2 van Diepen S, Katz JN, Albert NM; et al. (2017). "Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association". Circulation. 136 (16): e232–e268. doi:10.1161/CIR.0000000000000525.
- ↑ 2.0 2.1 2.2 Parlow S, Fernando SM, Pugliese M; et al. (2024). "Resource Utilization and Costs Associated With Cardiogenic Shock Complicating Myocardial Infarction: A Population-Based Cohort Study". JACC: Advances. 3 (8): 101047. doi:10.1016/j.jacadv.2024.101047.
- ↑ Tehrani BN, Truesdell AG, Psotka MA; et al. (2020). "A Standardized and Comprehensive Approach to the Management of Cardiogenic Shock". JACC: Heart Failure. 8 (11): 879–891. doi:10.1016/j.jchf.2020.09.005.
- ↑ Higuchi S, Kohsaka S, Sumita Y; et al. (2025). "Evolving Trends in Cardiogenic Shock Management in Acute Myocardial Infarction: Mortality, Discharge Outcomes, and Economic Implications". Scientific Reports. doi:10.1038/s41598-025-30300-1.
- ↑ 5.0 5.1 Hockstein MA, Horns JJ, Hanff T; et al. (2026). "Hospital Costs Associated With Mechanical Left Ventricular Unloading Devices During VA ECMO for Adult Cardiogenic Shock". Artificial Organs. 50 (6): 917–923. doi:10.1111/aor.70117.
- ↑ 6.0 6.1 Hochman JS, Sleeper LA, Webb JG; et al. (1999). "Early Revascularization in Acute Myocardial Infarction Complicated by Cardiogenic Shock". The New England Journal of Medicine. 341 (9): 625–634. doi:10.1056/NEJM199908263410901.
- ↑ Henry TD, Tomey MI, Tamis-Holland JE; et al. (2021). "Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association". Circulation. 143 (15): e815–e829. doi:10.1161/CIR.0000000000000959.
- ↑ Hochman JS, Sleeper LA, Webb JG; et al. (2006). "Early Revascularization and Long-Term Survival in Cardiogenic Shock Complicating Acute Myocardial Infarction". JAMA. 295 (21): 2511–2515. doi:10.1001/jama.295.21.2511. PMID 16757723.
- ↑ 9.0 9.1 Thiele H, Akin I, Sandri M; et al. (2017). "PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock". The New England Journal of Medicine. 377 (25): 2419–2432. doi:10.1056/NEJMoa1710261.
- ↑ 10.0 10.1 Thiele H, Akin I, Sandri M; et al. (2018). "One-Year Outcomes after PCI Strategies in Cardiogenic Shock". The New England Journal of Medicine. 379 (18): 1699–1710. doi:10.1056/NEJMoa1808788.
- ↑ Rihal CS, Naidu SS, Givertz MM; et al. (2015). "2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care". Journal of the American College of Cardiology. 65 (19): e7–e26. doi:10.1016/j.jacc.2015.03.036.
- ↑ Miller PE, Bromfield SG, Ma Q; et al. (2022). "Clinical Outcomes and Cost Associated With an Intravascular Microaxial Left Ventricular Assist Device vs Intra-Aortic Balloon Pump in Patients Presenting With Acute Myocardial Infarction Complicated by Cardiogenic Shock". JAMA Internal Medicine. 182 (9): 926–933. doi:10.1001/jamainternmed.2022.2735.
- ↑ 13.0 13.1 Møller JE, Engstrøm T, Jensen LO; et al. (2024). "Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock". The New England Journal of Medicine. 390 (15): 1382–1393. doi:10.1056/NEJMoa2312572.
- ↑ 14.0 14.1 Rao SV, O'Donoghue ML, Ruel M; et al. (2025). "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes". Journal of the American College of Cardiology. doi:10.1016/j.jacc.2024.11.009.
- ↑ 15.0 15.1 Thiele H, Zeymer U, Akin I; et al. (2023). "Extracorporeal Life Support in Infarct-Related Cardiogenic Shock". The New England Journal of Medicine. 389 (14): 1286–1297. doi:10.1056/NEJMoa2307227.
- ↑ Liao MT, Lin MH, Tsai HE; et al. (2022). "Risk Stratification and Cost-Effectiveness Analysis of Adult Patients Receiving Extracorporeal Membrane Oxygenation". Journal of Evaluation in Clinical Practice. 28 (4): 615–623. doi:10.1111/jep.13681.
- ↑ 17.0 17.1 Bhatia K, Jain V, Hendrickson MJ; et al. (2022). "Meta-Analysis Comparing Venoarterial Extracorporeal Membrane Oxygenation With or Without Impella in Patients With Cardiogenic Shock". The American Journal of Cardiology. 181: 94–101. doi:10.1016/j.amjcard.2022.06.059.
- ↑ 18.0 18.1 Taleb I, Giannouchos TV, Kyriakopoulos CP; et al. (2024). "Cost-Effectiveness of a Shock Team Approach in Refractory Cardiogenic Shock". Circulation: Heart Failure. 17 (11): e011709. doi:10.1161/CIRCHEARTFAILURE.124.011709.
- ↑ Papolos AI, Kenigsberg BB, Berg DD; et al. (2021). "Management and Outcomes of Cardiogenic Shock in Cardiac ICUs With Versus Without Shock Teams". Journal of the American College of Cardiology. 78 (13): 1309–1317. doi:10.1016/j.jacc.2021.07.044.
- ↑ 20.0 20.1 20.2 Sinha SS, Morrow DA, Kapur NK, Kataria R, Roswell RO (2025). "2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Evaluation and Management of Cardiogenic Shock". Journal of the American College of Cardiology. 85 (16): 1618–1641. doi:10.1016/j.jacc.2025.02.018.
- ↑ Lüsebrink E, Binzenhöfer L, Adamo M; et al. (2024). "Cardiogenic Shock". Lancet. 404 (10466): 2006–2020. doi:10.1016/S0140-6736(24)01818-X.
- ↑ 22.0 22.1 Shields GE, Wells A, Doherty P; et al. (2018). "Cost-Effectiveness of Cardiac Rehabilitation: A Systematic Review". Heart. 104 (17): 1403–1410. doi:10.1136/heartjnl-2017-312809.
- ↑ Shepard DS, Zakir S, Gaalema DE, Ades PA (2024). "Cost-Effectiveness of Cardiac Rehabilitation in Older Adults With Coronary Heart Disease". Journal of Cardiopulmonary Rehabilitation and Prevention. 44 (2): 107–114. doi:10.1097/HCR.0000000000000827.
- ↑ 24.0 24.1 Molloy C, Long L, Mordi IR; et al. (2024). "Exercise-Based Cardiac Rehabilitation for Adults With Heart Failure". Cochrane Database of Systematic Reviews (3): CD003331. doi:10.1002/14651858.CD003331.pub6.