Background: Emerging evidence supports a cardiovascular protective role of Cooled Dialysis (CD) in incident Hemodialysis (HD) patients. Whether this benefit can be extended to maintenance HD patients remains to be established. Objective: The aim of the present study was to assess the impact of CD by lowering Dialysate temperature (dt) 0.5^oC below Core Body Temperature (CBT), on minimizing myocardial ischemia in maintenance HD patients (>1 year on HD). Patients and Methods: from March 2019 to January 2021, we randomized one hundred maintenance HD patients to receive either Cooled Dialysis (dt - 0.5^oC below CBT, intervention) or Standard Dialysis (dt= CBT, control) for 12 months. Over the study period, serial measurements of ECG, echocardiography, and myocardial enzymes (CK-MB and Troponin-T) were performed for the whole study population as surrogates for myocardial ischemic injury. Results: By the end of 12-months, compared to Standard Dialysis (ST) patients, Cooled Dialysis (CD) patients had overall less incidence of new myocardial ischemia (composite surrogate outcomes: ECG, Echo and CK-MB) (p=0.032). In logistic regression analysis, CD was found to be independently protective against myocardial ischemia (OR 0.54, p-value 0.033, CI: 0.3-0.95).  Conclusion: In maintenance HD patients, Cooled Dialysis might help decrease myocardial ischemia with a reasonable safety profile. Further studies are warranted to explore these findings.