Pharmacy — Discharge Medication Advice after a Heart Attack
A hospital pharmacist writes a discharge medication advice letter to a 61-year-old man going home after a non-ST-elevation myocardial infarction. He leaves with five new medicines — including dual antiplatelet therapy — and no prior cardiac medication. The letter must explain the most critical medicines and their key instructions without overwhelming him.
Letter type
Discharge
Write to
Patient
Target length
200–230 words
The case notes
Patient: Mr Thomas Byrne, 61 years old; no previous cardiac history or regular medication
Diagnosis: NSTEMI; coronary angiogram showed two-vessel disease; drug-eluting stent to RCA (day 2)
Discharge medications (all new): Aspirin 75 mg OD (lifelong), ticagrelor 90 mg BD (12 months then review), atorvastatin 80 mg nocte, bisoprolol 2.5 mg OD, ramipril 2.5 mg OD
Priority 1 — dual antiplatelet: Aspirin and ticagrelor must BOTH be taken every day for 12 months; stopping either increases the risk of the stent blocking (stent thrombosis); this could be life-threatening
Ticagrelor side effects: Shortness of breath (common, usually mild, improves after a few weeks); bruising more easily than usual; aspirin-containing products must be avoided (no high-dose aspirin OTC)
Atorvastatin: Take at night; muscle aching is an uncommon side effect — report to GP or pharmacist if it develops
Ramipril: May cause a dry cough (common) — report if troublesome; dizziness on standing, especially first few days
Bisoprolol: Do not stop suddenly; GP will review the dose
Follow-up: GP renal check in 2 weeks; cardiology review 6 weeks; cardiac rehabilitation referral made
Task: Write a discharge medication advice letter to Mr Byrne explaining his new medicines and the most important instructions for going home.
Writing task
Write a discharge medication advice letter to Mr Byrne explaining his new medicines and the most important instructions for going home.
What to include, what to cut
The hardest mark to win is selection. The same case notes contain decision-relevant facts and distractors. Here is what an examiner expects to see in a Grade B letter for this scenario, and what should be left out.
Include
-
The dual antiplatelet instruction: both aspirin and ticagrelor every day for 12 months — never stop either without medical advice
This is the single most safety-critical instruction in the entire letter. Stopping ticagrelor early — for any reason, including a planned procedure — without medical advice risks stent thrombosis and a further heart attack. It must be stated explicitly and memorably.
-
Ticagrelor breathlessness — common, usually mild, do not stop without calling the team
Breathlessness is the most common reason patients self-discontinue ticagrelor. Pre-warning and a specific instruction to call rather than stop prevents this.
-
Do not stop bisoprolol suddenly
Abrupt beta-blocker withdrawal can cause rebound tachycardia and angina. A one-sentence warning is essential for a patient with no prior cardiac medication experience.
Leave out
-
Detailed cardiac anatomy or the stent procedure
The patient was counselled in hospital by the cardiology team. The discharge medication letter is about the medicines — not a replay of the procedure.
-
The full pharmacology of each medication
One plain sentence per drug on what it does is enough; detailed mechanisms are wrong register and waste the word count in a medication counselling letter.
Criterion in focus · Content
A post-MI discharge medication letter has two non-negotiable Content items: the dual antiplatelet must-not-stop instruction with the reason, and the breathlessness warning for ticagrelor with the do-not-stop instruction. Omitting either is a Content failure. The 2026 emphasis on clinically consequential omissions means even one missing safety item drops the Content grade.
Now write the letter — and find out what is blocking your Grade B
Write a 200–230 words discharge letter from these notes, paste it into the free checker for an instant read, then submit it for a human grade against all six criteria. Dr Mariam's team returns line-by-line feedback, from $12.