The 6-year cumulative incidence of ischemic heart disease (IHD) in 382 dialysis patients (mean age [SEM], 43 +/- 0.7 years) was studied. Of 101 patients with IHD, only 39 developed symptoms following dialysis (cumulative incidence, 20.8%). This group was older than those with IHD, and in 55%, IHD occurred in the first year of dialysis. Analysis by sex and race showed the rate of IHD in men and women to be similar, but the rate in whites was twice that in blacks. In men, the rate was not different from nondialysis men with similar coronary risk factors, whereas in dialysis women, the rate was twice that of nondialysis cohort. The development of IHD did not adversely affect long-term survival in patients without prior evidence of IHD. Death from myocardial infarction occurred in 3 of 320 patients ar risk. Atuopsy data in 33 patients revealed 70% stenosis of coronary arteries in 7, 4 of whom had antecedent disease. Our major conclusions are (a) the incidence of IHD during dialysis was not different from similarly matched nondialysis subjects; (b) the rate of IHD in dialysis women was greater than it was in nondialysis subjects; (c) coronary artery disease only affected long-term survival of patients with preexisting disease; (d) autopsy data did not suggest accelerated atherosclerosis.