Chronic kidney disease (CKD) has emerged as a critical global public health concern. This condition is strongly associated with an increased risk of atherosclerotic cardiovascular disease and acute coronary syndromes (ACSs), which have been recently renamed as acute myocardial ischaemic syndromes (AMIS). In CKD patients, the atypical presentation of symptoms complicates the diagnosis and management of angina, a condition that can, if not promptly addressed, rapidly progress to myocardial infarction (MI). Traditional diagnostic tools, such as the electrocardiogram and cardiac biomarkers, are less reliable in this population due to CKD-related baseline alterations, necessitating advanced imaging techniques for accurate assessment. Management strategies for transient myocardial ischaemia in CKD must also carefully balance the risk related to myocardial ischaemia against potential complications from invasive procedures, such as further renal impairment and bleeding. Tailored therapeutic approaches, including adjusted medication regimens and innovative revascularization techniques, are crucial to improve outcomes in this high-risk population. Additionally, asymptomatic MI is notably prevalent in CKD, often remaining undetected and posing significant prognostic implications. The interplay of traditional and non-traditional risk factors, such as uraemia-induced toxicity and chronic inflammation, further exacerbates the risk for plaque instability in CKD patients. This review highlights the necessity of a multidisciplinary approach in managing myocardial ischaemia in CKD, incorporating meticulous risk stratification and personalized treatment plans.