OBJECTIVES: To determine the cost-effectiveness of Heart Failure (HF) clinics compared to standard care for HF patients in Ontario, Canada. METHODS: We performed a cost-effectiveness analysis, with a 12-year time horizon, from the perspective of the Ontario Ministry of Health. We compared a standard care cohort, consisting of all patients admitted to hospital with HF in 2005, to a hypothetical cohort treated in HF clinics. Survival curves describing the natural history of HF were constructed using mortality estimates from EFFECT study. Survival benefits and resource uptake associated with HF clinics were estimated from a meta-analysis of published trials. HF clinics costs were obtained by costing of a representative clinic in Ontario. Health-related costs associated with physician visits, hospitalizations, emergency department visits, same day surgeries and medication use, were determined through linkage to administrative databases. Outcome measures included life expectancy, costs (in 2008 CAD$) and the incremental cost-effectiveness ratio (ICER). A budget impact analyses was performed to estimate affordability. RESULTS: The systematic review determined that HF clinics were associated with a 29% reduction in all-cause mortality (risk ratio [RR] 0.71; 95% Confidence Interval [CI] 0.56-0.91) but a 12% increase in hospitalizations (RR 1.12; 95% CI 0.92-1.135). The cost of care in HF clinics was $52 per 30 patient-days. Projected life-expectancy of HF clinic patients was 3.91 years, compared to 3.21 years for standard care. The 12 year cumulative cost per patient in the HF clinic group was $66,532 versus $53,638 in the standard care group. The ICER was $18,259/life year gained. The average annual cost for HF clinic implementation was $17 million in Ontario. CONCLUSIONS: Multi-disciplinary HF clinics reduce mortality and increase life expectancy. Despite increasing overall costs due to increased late hospitalizations, HF clinics appear to be a cost effective way of delivering ambulatory care to HF patients.