Background: Cardiovascular disease and kidney disease are linked by a common etiology and together result in a very poor prognosis& the most common complication during hemodialysis is acquired hypotension and that may refers to hidden myocardial ischemia as it is likely seems the interplay between CKD and cardiovascular disease risk factors.Methods: A prospective cohort study including 30 patients with GFR > 60 ml/ min/ 1.73m2 and on regular dialysis and no history of cardiovascular disease were subjected to clinical assessment, laboratory investigations, electrocardiography, echocardiography and MPI study to asses presence of myocardial ischemia.Results: The prevalence of MPI ischemia in patients of chronic kidney disease and acquire hypotension during dialysis session recorded 40% positivity in comparison to 10% in non-hypotensive patients with Odd ratio (OR) =6 fold.Conclusion: The present study could concur that patients with CKD should be risk – stratified on initial contact and should receive aggressive medical management for cardiac risk factors.