Cost-utility analysis of the wearable cardioverter defibrillator in high-risk post-myocardial infarction patients in the Spanish healthcare system

Introduction: Patients with reduced left ventricular ejection fraction after myocardial infarction (MI) remain at increased risk of sudden cardiac death during the early post-MI period, before implantable cardioverter defibrillator eligibility is confirmed. The wearable cardioverter defibrillator (WCD) offers temporary protection during this vulnerable interval within post-MI care. We evaluated the cost-utility of WCD therapy plus guideline-directed medical therapy (GDMT) vs. GDMT alone from the Spanish healthcare system perspective. Methods: A cost-utility analysis used a Markov state-transition model with monthly cycles and a lifetime horizon for a hypothetical cohort of 1,000 post-MI patients with left ventricular ejection fraction 35% or less at discharge. Early mortality inputs were based on the as-treated VEST analysis; longer-term risks and utilities came from published sources. Direct medical costs used Spanish sources (2025 euros). Deterministic and probabilistic sensitivity analyses were conducted, including a scenario analysis using per-protocol effectiveness estimates from the VEST trial. Results: WCD plus GDMT was associated with projected gains of 0.53 life years and 0.43 quality-adjusted life years (QALYS) vs. GDMT alone (12.83 vs. 12.30 life years; 9.59 vs. 9.16 QALYs). Total lifetime costs were €113,290 vs. €102,032, giving incremental costs of €11,259 and an incremental cost-effectiveness ratio of €26,145 per QALY gained, below the €30,000 threshold. The probability of cost-effectiveness was 78.3% for patients during the early post-MI period. Conclusions: In Spain, temporary WCD use alongside GDMT after MI shows potential to improve health outcomes at an incremental cost that falls within commonly cited willingness-to-pay thresholds. These findings support adoption of WCD therapy for patients at transiently high risk of sudden cardiac death, while highlighting the importance of appropriate patient selection and adherence in clinical practice.