Chest Pain and Dyspnea During Dialysis: Differential Diagnosis and Management

Immediate Actions Required

The American College of Cardiology recommends performing a 12-lead ECG immediately to evaluate for ischemic changes in dialysis patients with chest pain 1, 2
Transfer by EMS to an acute care setting is necessary if the patient has acute unremitting chest pain or if the ECG shows ischemic changes 1, 2
Administer oxygen and initiate cardiac monitoring following standard protocols 2
Follow standard acute coronary syndrome protocols per ACC/AHA guidelines if ECG shows ischemia or the patient is unstable 1, 2, 3

Myocardial ischemia/infarction is induced by hypotension or tachyarrhythmias during dialysis in patients with underlying coronary artery disease 1
Acute MI in dialysis patients is less frequently associated with typical chest pain compared to non-dialysis patients and may instead present with diaphoresis, dyspnea, or unexplained hemodynamic instability 1, 2
Cardiovascular disease is the leading cause of death in maintenance hemodialysis patients, responsible for at least 50% of deaths 4
Dialysis patients have exceptionally high cardiovascular disease prevalence, making them particularly vulnerable to cardiac events during treatment 1, 2

Rapid ultrafiltration can precipitate hypovolemia and hypotension, compromising tissue perfusion and potentially triggering myocardial ischemia 5, 4
Each 10 mm Hg rise in mean arterial pressure independently increases the risk of de novo cardiac failure by 44% 6, 7
Fluid overload from inadequate achievement of dry weight can precipitate acute decompensation 5, 4

Perform regular assessment of dry weight to prevent intradialytic hypotension 1
Use slower ultrafiltration rates in patients with cardiovascular instability 1, 2
Tolerance to ultrafiltration varies; some patients may require slow ultrafiltration during longer sessions than the standard 4 hours 3 times weekly 5, 4
Reduce dialysate temperature from 37°C to 34-35°C to increase peripheral vasoconstriction and cardiac output 1
Ensure appropriate anticoagulation during dialysis to prevent pulmonary embolism 1, 2

Interpret troponin elevations with caution but do not dismiss them—while troponins may be chronically elevated in ESRD due to reduced clearance, rising trends in the context of chest pain indicate acute coronary syndrome until proven otherwise 3
BNP/NT-proBNP should be interpreted with caution as these are inversely associated with GFR, but elevations still correlate with left ventricular dysfunction even in CKD 3
Obtain chest radiograph promptly to verify catheter position and rule out other causes 2

Do not attribute elevated troponins solely to CKD—evaluate trends and clinical context, as elevations with chest pain warrant full acute coronary syndrome evaluation 3
Do not dismiss atypical presentations—dialysis patients may have silent ischemia or present with dyspnea alone rather than chest pain 2
Do not withhold standard cardiac interventions based on kidney disease status—the level of care for ischemic heart disease should not be prejudiced by CKD 3
Do not assume all chest pain is cardiac—gastroesophageal reflux can also cause chest pain during dialysis 1