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Introduction Optimising NICE guideline-directed medical therapy (GDMT) before discharge is vital for reducing morbidity and mortality following acute coronary syndrome (ACS). Ward-based pharmacist-led interventions have the potential to enhance adherence to GDMT, improve medication safety, and transitions between secondary and primary care. However, data on the efficacy of pharmacist interventions is limited.Methods We aimed to assess the role of ward-based pharmacist interventions through a prospective study on patients admitted with ACS between August and December 2024. Patients who died during admission, were on end-of-life care and had inpatient cardiac surgery were excluded. Data on patient demographics, cardiovascular and bleeding risk factors was analysed alongside secondary prevention therapies, encompassing all four pillars: antithrombotics, renin-angiotensin-aldosterone inhibitors (RAASi), beta-blockers, and lipid-lowering therapy. Pharmacist interventions focusing on efficacy, safety, and communication were delivered by both prescriber and non-prescriber pharmacists. Adherence to GDMT was re-assessed at 30 days.Results We included 100 consecutive patients (68 males, 32 females; median age 70 years), and analysed 219 pharmacist interventions. On discharge, 82% were prescribed a RAASi, 81% a beta-blocker, and 91% a high-intensity statin. Pharmacist interventions improved both safety and efficacy of antithrombotics by switching 7% of antiplatelets to clopidogrel in patients on concurrent oral anticoagulants and reducing clopidogrel-omeprazole co-prescriptions by 89%. Most importantly, in high-bleeding risk patients, pharmacist actions increased gastroprotective therapy prescriptions 1.25-fold. Moreover, 13% more patients were discharged on an appropriate atorvastatin dose via initiation, up-titration, or mitigation of drug interactions. On discharge, pharmacists led 60% of communications regarding RAASi and beta-blocker up-titration. All patients received a clearly stated duration of antiplatelet therapy from the pharmacists which resulted in 17% improvement over standard care. At 30-days follow-up, lower discontinuation and down-titration rates were observed viz 15.9% for RAASi, 9.9% for beta-blockers, and 8.8% for high-intensity statins compared to the literature.Conclusions We have shown that ward-based pharmacist-led interventions significantly enhanced GDMT compliance and communication during transition to primary care post-ACS. Our high adherence to NICE guideline-based therapy at discharge followed by lower-than-expected decline in adherence at 30-days is a unique opportunity to improve patient care. While multifaceted strategies across all sectors are warranted to sustain long-term benefits, pharmacist-led interventions may prove to be cost-effective and reduce recurrent cardiovascular events.