Management of Intradialytic Chest Pain

For patients experiencing acute unremitting chest pain during hemodialysis, immediate transfer by EMS to an acute care setting is recommended. 1

Initial Assessment and Management

Immediately perform a 12-lead ECG to evaluate for ischemic changes, as myocardial ischemia is the most frequent serious cause of chest pain during dialysis 1
While arranging transfer, consider the following immediate interventions:
- Reduce or temporarily stop ultrafiltration to prevent further blood pressure drop 2
- Place the patient in Trendelenburg position to improve venous return if hypotension is present 2
- Administer supplemental oxygen to improve tissue oxygenation 2
- For suspected acute coronary syndrome with no contraindications, consider sublingual nitroglycerin, but use with caution in volume-depleted patients 3

Myocardial ischemia/infarction - often induced by hypotension or tachyarrhythmias during dialysis in patients with CAD 1
Pericarditis - common in dialysis patients and may present with chest pain 4, 5
Arrhythmias - triggered by electrolyte shifts during dialysis 4

Hypotension - due to rapid ultrafiltration 2
Hemolysis - can cause chest discomfort during dialysis 1
First-use syndrome - hypersensitivity reactions to dialysis membranes causing chest pain, dyspnea, and hypotension 6

Pulmonary embolism - particularly with inadequate anticoagulation 1, 4
Aortic dissection - may present atypically in dialysis patients, sometimes without classic chest pain 7
Gastroesophageal reflux 1
Subclavian steal syndrome 1
Musculoskeletal disorders 1, 8
Vascular access complications - including vessel perforation by catheter 1

Perform regular assessment of dry weight to prevent intradialytic hypotension 4, 2
Consider sodium profiling (starting with higher sodium concentration and gradually decreasing it) to maintain vascular stability 2
Use slower ultrafiltration rates in patients with cardiovascular instability 4, 2
Ensure appropriate anticoagulation during dialysis to prevent pulmonary embolism 4
Consider reducing dialysate temperature from 37°C to 34-35°C to increase peripheral vasoconstriction and cardiac output 2
For patients with recurrent chest pain during dialysis:
- Review and potentially adjust antihypertensive medications 2
- Consider administering midodrine before dialysis to prevent hypotension 2
- Limit fluid intake between dialysis sessions to reduce interdialytic weight gain 2

AMI in patients undergoing dialysis is less frequently associated with chest pain than in non-dialysis patients - be alert for warning signs like diaphoresis or dyspnea 1
Patients on dialysis have a high prevalence of cardiovascular disease, making them particularly vulnerable to cardiac events during dialysis 1
When using nitroglycerin for suspected cardiac chest pain, be aware that it may cause severe hypotension, particularly in volume-depleted patients such as those on dialysis 3
Pain during dialysis is often undertreated - consider appropriate pain management strategies based on the identified cause 8
Cardiac testing for patients on dialysis with chest pain should be the same as for non-dialysis patients once they are stabilized 1