By: Aymon Choudhury, PharmD Candidate c/o 2027

Acute coronary syndrome (ACS) includes three clinical conditions: unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). These conditions are a major cause of morbidity and mortality worldwide, requiring rapid diagnosis, timely intervention with reperfusion, guideline-directed drug therapy, coordinated transitions of care between healthcare settings, and long-term secondary prevention strategies for effective management and the prevention of recurrent cardiovascular events following MI. Standard therapy commonly includes antiplatelet agents, anticoagulants, beta-blockers, high-intensity statins, ACE inhibitors, angiotensin receptor blockers (ARBs), and other supportive therapies based on clinical presentation. Following a percutaneous coronary intervention (PCI), which is a procedure used to restore coronary blood flow in STEMI, the cornerstone of ACS management is dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor such as clopidogrel. Given the complexity of the comprehensive care process needed for patients with ACS, pharmacists play an increasingly important role in optimizing ACS pharmacotherapy and management across both emergency and post-MI care settings.

Pharmacists in the Emergency Department and Acute ACS Management

Under the 2025 ACS guidelines for the initial evaluation and management of suspected ACS, clear guidelines for rapid assessment are provided to reduce mortality and shorten reperfusion times. For suspected ACS, a 12-lead ECG should be obtained and interpreted within 10 minutes of first medical contact (FMC). For suspected STEMI, the FMC-to-first-device timeframe is 90 minutes or less, the “door-to-balloon” benchmark for reperfusion with PCI, and each 30-minute delay is associated with a 7.5% increase in 1-year mortality.¹ Early notification and direct EMS transfer of patients with STEMI to PCI-capable facilities are also strongly recommended, enabling prehospital implementation of care processes that significantly reduce reperfusion times. These guidelines emphasize the critical importance of rapid evaluation and coordinated emergency care systems for patients presenting with ACS.

The role of a hospital pharmacist has evolved significantly over time, and integrating clinical pharmacists into critical care teams has been associated with improvements in care. Such improvements include better patient-specific outcome measures, medication management, timely administration, therapy optimization, and medication safety.² Emergency pharmacists (EPh) are increasingly recognized as valuable members of multidisciplinary response teams managing time-sensitive emergencies. During acute resuscitative events such as trauma, stroke, MI, cardiac arrest, and airway compromise, EPh responsibilities may include ensuring appropriate medication selection and dosing, preparing medications for immediate administration, maintaining a readily available drug supply, and providing real-time clinical recommendations.

Evidence suggests that pharmacist participation in emergency response teams improves several aspects of resuscitative care. EPh presence has been associated with improved compliance with advanced cardiac life support (ACLS) guidelines, reduced time to analgesia, and improved door-to-balloon times for patients with MI.³ Similarly, a scoping review evaluating pharmacist involvement, particularly in cardiac arrest and trauma resuscitation, reported reductions in medication errors, improved adherence to ACLS guidelines, faster trauma care, improved performance of ACLS-associated tasks, and reduced healthcare costs.⁴ Collectively, these findings demonstrate that emergency pharmacists provide valuable expertise to acute care teams and contribute to safer and more efficient management of cardiovascular emergencies.

Pharmacists can also directly influence time-sensitive care in acute MI. One study examined the presence of a dedicated emergency pharmacist and its association with door-to-balloon and door/diagnosis-to-cardiac catheterization laboratory (CCL) times. Specifically, EPh involvement reduced door-to-diagnosis-to-CCL time by 13.1 minutes and door-to-balloon time by 11.5 minutes, while also increasing the likelihood of meeting the recommended STEMI reperfusion door-to-balloon time benchmark of 90 minutes or less.⁵ By supporting rapid medication preparation, protocol adherence, and coordination during STEMI patient presentation and early evaluation, pharmacists can streamline workflows, reduce patient time in the emergency department, and ultimately improve patient outcomes.

Pharmacist Role in Post–Myocardial Infarction Care, Secondary Prevention, and Transitions of Care

While pharmacists contribute significantly to acute ACS management, their role extends beyond initial hospitalization and into long-term secondary prevention and post-discharge care. Following stabilization of acute coronary syndromes, ongoing pharmacologic management, patient education, and coordinated follow-up are critical to preventing recurrence. Pharmacists play an important role during this phase of care by improving adherence, optimizing therapy, and supporting transitions of care.

Nonadherence to secondary prevention measures has frequently been found to be poor in several studies examining medication continuation and prescription initiation after discharge. Poor adherence to medications like beta-blockers, clopidogrel, and statins has been associated with increased short- and long-term mortality, and nonadherence to DAPT after stent implantation increases the risk of stent thrombosis.⁶ Common causes of nonadherence include forgetfulness, patient perceptions of medication necessity, and cost. A systematic review of randomized controlled trials found that pharmacist care improved medication adherence and blood pressure and lipid management.⁷ Improvements in these related outcomes are key factors in reducing recurrent MI and mortality.

Individual trials further support the effectiveness of pharmacist involvement in improving adherence. One randomized controlled trial in Vietnam found that pharmacist-provided pre-hospital and post-hospital medication counseling, patient education, and medication aids improved patient adherence by more than 13% during the first three months after discharge.⁸ The feasibility of these interventions should be noted, as they did not require costly resources. A similar randomized trial evaluating pharmacist-led medication reconciliation, patient education, provider/cardiologist collaboration, and voice messaging for educational and medication refill reminders demonstrated improved adherence to clopidogrel, beta-blockers, statins, and antihypertensive medications among ACS patients.⁹ This study also highlighted costs similar to those of the usual care intervention. Electronic reminders and telephone education calls have demonstrated benefits for medication adherence and are already in use in community pharmacies. These findings support considering further implementation of pharmacist services in ACS care to optimize therapy and improve adherence post-ACS, which leads to improved short-term and long-term therapeutic outcomes and prevents rehospitalization.

Lifestyle modification and patient education also play a critical role in comprehensive post-MI patient care regimens. Pharmacists can counsel patients on important points such as medication indications, doses/frequencies, adverse effects, adherence, and lifestyle strategies, including physical activity, alcohol moderation, smoking cessation, and dietary changes. Patients who remain sedentary, continue smoking, or do not follow dietary recommendations have up to a fourfold increased risk of cardiovascular events.¹⁰ One prospective interventional study evaluating the effects of clinical pharmacist-led education and lifestyle counseling on various outcomes demonstrated significant reductions in fasting and postprandial blood glucose, systolic and diastolic blood pressure, and total cholesterol levels, as well as lower rates of medication nonadherence, 30-day hospital readmissions, alcohol use, and smoking after follow-up.¹¹ Outpatient pharmacists were also associated with improving adherence by helping patients restart their diabetes mellitus medications. Pharmacists can therefore play a role in improving patient outcomes by emphasizing key lifestyle strategies proven to reduce mortality and rehospitalization.

Seamless transitions of care from inpatient to outpatient settings are another important factor in cardiovascular outcomes. During this transition, it is important to clarify key points regarding the patient’s post-ACS medications and follow-up appointments, and to close any care gaps. Pharmacists can support this transition regardless of the setting; they can contribute on an inpatient cardiology pharmacy team or as the patient’s outpatient pharmacist. One study demonstrated the benefits of expanded pharmacist participation for patients with ACS, including working on a multidisciplinary team, partnering with supervising clinicians under a CPA (collaborative practice agreement), managing bedside medication delivery, and providing pre- and post-discharge care and counseling.¹² Inpatient pharmacists reviewed the patient’s discharge medications, counseled on risks/benefits and potential adverse effects, introduced the outpatient pharmacist for follow-up, and provided a custom flyer with key points and contact information. The outpatient pharmacist verified post-discharge follow-up appointments with a physician, reviewed discharge medications, addressed lifestyle modifications, adherence, and comorbidities, monitored therapy for additional adjustments or tests, and scheduled follow-up appointments as needed. This pharmacist-led transition-of-care program showed improvements in follow-up visits within 1 month of discharge, 30-day post-discharge hospital readmission rates, and an increased likelihood of being discharged with ACS-related prescriptions, such as statins and P2Y12 inhibitors. This demonstrates that pharmacists can have a much wider role than adherence and referral to treatment alone.

Additionally, ACS guidelines recommend transitioning patients into cardiac rehabilitation to reduce mortality, MI, and hospital readmissions, and to improve functional status.¹ In this setting, clinical pharmacists can expand standard medical care for patients with ACS by reviewing discrepancies in patients’ records, identifying and managing drug-related problems (DRPs), providing detailed drug/disease information, and reinforcing lifestyle modifications. One randomized trial evaluating the impact of such pharmacy services during cardiac rehabilitation reported significant improvement in DRP resolution, patient knowledge of secondary prevention measures, drug adherence after 3 months, and reductions in heart rate, blood pressure, and LDL.¹³ The benefits of utilizing pharmacist participation in post-ACS cardiology services and outpatient follow-up are further emphasized by another study examining the effects of a consultant cardiology pharmacist collaborating within a cardiologist clinic. This study similarly demonstrated improved secondary prevention medication optimization and adherence, reduced patient concerns, and lower readmission rates. Additional benefits of using pharmacist services include increasing outpatient capacity and reducing wait times from discharge to clinic attendance.¹⁴ Therefore, pharmacists can contribute to long-term ACS management by supporting personalized post-ACS patient care, thereby improving patient satisfaction, adherence, continuity of care, and long-term outcomes.

Clinical pharmacists play an important role across patient care settings for patients with ACS. Evidence demonstrates that pharmacist involvement in emergency departments can improve medication safety, enhance adherence to resuscitation protocols, and reduce treatment delays. Beyond the acute phase, pharmacists support secondary prevention and risk management by optimizing medication therapy, providing patient education, and implementing adherence interventions. In transitions of care and outpatient settings, pharmacists can further address medication problems, improve continuity of care, and reduce hospital readmissions. As multidisciplinary models of cardiovascular care continue to evolve, expanding pharmacist participation in ACS management teams may be an effective strategy to improve outcomes in patients with MI or at risk of MI.

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