Managing Acute Coronary Syndrome (ACS) complicated by pulmonary edema in patients with End-Stage Renal Disease (ESRD) on dialysis is particularly challenging, requiring a balance between effective decongestion and hemodynamic stability. Traditionally, Hemodialysis (HD) is considered first line because it removes fluid rapidly; however, aggressive ultrafiltration during HD often precipitates intradialytic hypotension and arrhythmia, potentially worsening myocardial ischemia [1]. In contrast, Peritoneal Dialysis (PD) provides gradual, continuous ultrafiltration and avoids abrupt intravascular volume shifts. In heart-failure populations, PD-compared with HD-has been associated with fewer blood pressure fluctuations and a lower incidence of intradialytic hypotension [2-4]. Despite these advantages, in daily practice we frequently encounter skepticism from intensivists and cardiologists, who doubt PD’s ability to achieve adequate decongestion in ACS-related pulmonary edema and therefore recommend switching to HD.