Abstract Background Re-hospitalization after discharge for acute decompensated heart failure is a common problem. Low-socioeconomic urban patients suffer high rates of re-hospitalization and often over-utilize the Emergency Department (ED) for their care. We hypothesized that early consultation with a cardiologist in the ED can reduce re-hospitalization and healthcare costs for low-socioeconomic urban patients with acute decompensated heart failure. Methods 392 patients treated at our center for acute decompensated heart failure received standardized education and follow-up. Patients who returned to the ED received early consultation with a cardiologist. 392 patients who received usual care served as controls. 30- and 90-day re-hospitalization, ED re-visits, heart failure symptoms, mortality, and healthcare costs were recorded. Results Despite guideline-based education and follow-up, the rate of ED re-visits was not different between the groups. However, the rate of re-hospitalization was significantly lower in patients receiving the intervention compared with controls (OR=0.592), driven by a reduction in the risk of readmission from the ED (0.56 vs. 0.79 respectively). Patients receiving the intervention accumulated 14% fewer re-hospitalized days than controls and 57% lower 30-day total healthcare cost. Despite the reduction in healthcare resource consumption, mortality was unchanged. After accounting for the total cost of intervention delivery, the healthcare cost savings was substantially greater than the cost of intervention delivery. Conclusions Early consultation with a cardiologist in the ED as an adjunct to guideline-based follow-up is associated with reduced re-hospitalization and healthcare cost for low-socioeconomic urban patients with acute decompensated heart failure.