Management of Intradialytic Chest Pain

Initial Assessment and Management

The American College of Cardiology and Circulation recommend immediately performing a 12-lead ECG to evaluate for ischemic changes, as myocardial ischemia is the most frequent serious cause of chest pain during dialysis 1, 2, 3
For patients experiencing acute unremitting chest pain during hemodialysis, immediate transfer by EMS to an acute care setting is recommended by the American Heart Association and the American College of Cardiology 1, 4, 2, 3, 5, 6

Myocardial ischemia/infarction is often induced by hypotension or tachyarrhythmias during dialysis in patients with coronary artery disease, according to the American College of Cardiology and Circulation 1, 2, 3
The American College of Cardiology notes that gastroesophageal reflux can cause chest pain during dialysis 1, 2
Subclavian steal syndrome can also cause chest pain during dialysis, as reported by the American College of Cardiology and Circulation 1, 2
Vascular access complications, including vessel perforation by catheter, can cause chest pain during dialysis, according to the American College of Cardiology and Circulation 1, 2

The American Society of Nephrology recommends performing regular assessment of dry weight to prevent intradialytic hypotension, although this specific recommendation is from Praxis Medical Insights 7, 8
The use of slower ultrafiltration rates in patients with cardiovascular instability is recommended by Praxis Medical Insights to prevent hypotension 7, 8
Ensuring appropriate anticoagulation during dialysis can help prevent pulmonary embolism, as noted by Praxis Medical Insights 7
Reducing dialysate temperature from 37°C to 34-35°C can help increase peripheral vasoconstriction and cardiac output, according to Praxis Medical Insights 8

The American College of Cardiology notes that acute myocardial infarction in patients undergoing dialysis is less frequently associated with chest pain than in non-dialysis patients, and healthcare providers should be alert for warning signs like diaphoresis or dyspnea 1, 2
Patients on dialysis have a high prevalence of cardiovascular disease, making them particularly vulnerable to cardiac events during dialysis, according to the American College of Cardiology and Circulation 1, 2, 3
Cardiac testing for patients on dialysis with chest pain should be the same as for non-dialysis patients once they are stabilized, as recommended by the American College of Cardiology and Circulation 1, 2

Obtain a chest radiograph promptly to verify catheter position, as recommended after placement of internal jugular catheters, and repeat if malposition is suspected, according to the American Journal of Kidney Diseases guidelines 9, 10
Administer oxygen and initiate cardiac monitoring, following standard protocols per American Heart Association guidelines 11
Follow standard acute coronary syndrome protocols per American College of Cardiology/American Heart Association guidelines if ECG shows ischemic changes or patient is unstable 11

Verify catheter position with imaging before first use and if malfunction occurs, as recommended by the American Journal of Kidney Diseases 9, 10
Use slower ultrafiltration rates in patients with cardiovascular instability to prevent hypotension-induced chest pain, although no specific guideline society is mentioned in the reference
Ensure appropriate anticoagulation during dialysis to prevent pulmonary embolism, although no specific guideline society is mentioned in the reference
The American College of Cardiology recommends following standard acute coronary syndrome protocols if ECG shows ischemic changes or patient is unstable 11