Patients undergoing chronic hemodialysis are at high risk of dying of cardiovascular disease. In large part, this risk relates to the high incidence of significant hypertension, which generally precedes the development of ESRD and the initiation of chronic hemodialysis. Once hemodialysis has begun, the dialysis patient is subjected to several hemodynamic stresses which, along with hypertension and elevated total peripheral vascular resistance, contribute to a sustained elevation of left ventricular work. Further contributions to cardiovascular morbidity and mortality derive from acquired valvular disease and pericarditis. The influence of underlying systemic diseases, with the exception of diabetes mellitus, is relatively small, while the existence of a specific uremic cardiomyopathy remains doubtful. On the other hand, the risk of IHD and coronary atherosclerosis in the dialysis population is high, but appears to be no greater than that of a non-dialysis population with comparable risk factors. Several population charcteristics which are not related to renal failure, namely age, race and sex, are important for coronary risk in the dialysis population. Hypertension and chronic pyelonephritis also appear to contribute significantly to the development of symptomatic IHD, and the hemodynamic and metabolic alterations pursuant to hemodialysis have considerable potential to provoke ischemic symptoms in patients with or without advanced coronary atherosclerosis. The highest mortality from coronary artery disease is observed in patients with preexistent ischemic heart disease. It remains to be proven that abnormalities of lipid and carbohydrate metabolism associated with ESRD play an important role in the genesis of coronary heart disease in the dialysis population.