What could be causing chest tightness and pain with dyspnea in an adult patient with end-stage renal disease (ESRD) and potential comorbidities such as hypertension, diabetes, or cardiovascular disease during dialysis sessions?

Chest Pain and Dyspnea During Dialysis: Differential Diagnosis and Management

This patient is most likely experiencing myocardial ischemia or infarction, which is the most frequent serious cause of intradialytic chest pain, and requires immediate 12-lead ECG and potential transfer to an acute care setting. 1

Immediate Actions Required

• Perform a 12-lead ECG immediately to evaluate for ischemic changes, as this is the first priority in any dialysis patient with chest pain 1, 2
• Transfer by EMS to an acute care setting 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

Primary Differential Diagnoses

Cardiovascular Causes (Most Common and Life-Threatening)

Myocardial Ischemia/Infarction

• This is induced by hypotension or tachyarrhythmias during dialysis in patients with underlying coronary artery disease 1
• Critical caveat: 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, 5
• Dialysis patients have exceptionally high cardiovascular disease prevalence, making them particularly vulnerable to cardiac events during treatment 1, 2

Congestive Heart Failure

• CHF is highly prevalent in ESRD and represents a leading cause of death 6
• Fluid overload from inadequate achievement of dry weight can precipitate acute decompensation 4
• Each 10 mm Hg rise in mean arterial pressure independently increases the risk of de novo cardiac failure by 44% 4

High-Output Heart Failure from Arteriovenous Access

• AVDA can cause symptoms of heart failure, dyspnea, and pulmonary hypertension 7
• Revision or closure of AVDA can markedly improve dyspnea and hemodynamic manifestations 7

Other Important Causes

Dialysis-Related Hypotension

• Rapid ultrafiltration can precipitate hypovolemia and hypotension, compromising tissue perfusion and potentially triggering myocardial ischemia 4
• Some patients experience paradoxical blood pressure increases during fluid removal 4

Pericarditis/Pericardial Tamponade

• Seen in less than 10% of dialysis patients but can present with chest discomfort and progress to tamponade 2, 5
• Best diagnosed by clinical examination and echocardiography 5

Subclavian Steal Syndrome

• Related to vascular access and can cause chest pain during dialysis 1, 2

Vascular Access Complications

• Vessel perforation by catheter can cause chest pain 1
• Verify catheter position with imaging if malposition is suspected 2

Pulmonary Embolism

• Can occur if anticoagulation during dialysis is inadequate 1, 2

Prevention Strategies

Volume Management

• 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 4

Dialysis Modifications

• 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

Blood Pressure Control

• Hypertension is the single most important predictor of coronary artery disease in uremic patients 4
• 60-90% of maintenance HD patients have hypertension, and cardiovascular disease is responsible for at least 50% of deaths 4

Diagnostic Workup Beyond Initial ECG

Cardiac Biomarkers

• 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

Imaging

• Obtain chest radiograph promptly to verify catheter position and rule out other causes 2
• Echocardiography can assess for pericardial effusion, tamponade, and cardiac function 5

Common Pitfalls to Avoid

• 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