Daily chest pain especially during and after running

[Marti138]

I am 46 years old with complaints of continued chest pain.  I am physically active; running long distance (marathons).
I have recurrent chest pain.  frequently later in the day.
when i go out running, if I start to fast and run hills; I get the chest pain.  usually if I back off it gets better.  During a marathon race, the pain comes on later in the race and doesn't really go away, typically hurts mid chest radiating to my shoulder blades, up my neck.  kind of a crushing pain.  also during the marathon when the pain gets worse, I also get some palpitations--PVC possibly.  but those usually go away if I back off on my pace.  sometimes with the pain I also get a cough, and it hurts more with the cough.
I have had a very extensive cardiac workup.  I do have a S1. S2 murmur.  mild tricusp regurg, mildly thickened mitral valve leaflets,  mild thickened aortic valve (age related?)  
I have had echo, cardiac cath, nuclear studies.....no reason for the pain??  the pain didn't come on when i had the stress test....i guess they didn't challenge me enough?  my hr goes up to 140 and stays there for over an hour during my running, but does recover down to 70's  but occasionally will skip beats if I abruptly stop after running hard.
I have also had extensive GI workup to include endoscopy, colonoscopy, the test to check for esophageal spasm(cant remember what that was called) HIDA scan.  I am now starting to see and endocrinologist--i am mildly anemic. all other hormones were ok.

I have been living with this pain for over a year,  I sometimes feel like a hypochondriac and siince have not gone to see any docs....just try to continue with the pain.  my cardiologist did offer me Ranexa which did to seem to help some.  the pain wasnt as bad and my energy levels were more normal.   And I have some metroprolol that my doc prescribed that I try when the pain is bad and my hr is high enough (low resting HR of 40) it usually helps the pain.
thanks,
marti

[CCFCardio MD2]

I'm sorry to hear you're having continued chest pain.  I'm sure it's frustrating to continue to have symptoms without a clear answer.  The main concern in this case would be coronary artery disease.  However, if your cardiac catheterization was normal, coronary artery disease is very unlikely as cardiac cath gives a relatively definitive diagnosis.  One thing to consider is coronary vasospasm, though your symptoms don't sound consistent with this diagnosis.  If your resting HR is 40 I would avoid the metoprolol as it likely isn't helping much.  If your cardiac catheterization was normal, I would stop the Ranexa as it also isn't helping much.  The fact that your chest pain occurs with exertion is concerning for coronary disease, but again I would ask your doctor if your cardiac catheterization was normal.  Given your baseline cardiovascular fitness I'm not surprised that your stress test was normal.  You could consider a cardiac CT or MRI as on rare occasions aberrant take-offs of your coronary arteries can cause chest pain with exertion.  

Otherwise, consider pulmonary or gastrointestinal etiologies.  The fact that your pain gets worse with coughing points more toward a pulmonary or musculoskeletal process, though these shouldn't persist for a year.  Reflux of stomach acid can cause symptoms like this so make sure you have tried a trial of proton pump inhibitors such as omeprazole.  

Keep in touch with your physician about other possible and more rare etiologies if your pain persists.  

Best of luck.

[Marti138]

Thanks,  I do feel that my cardiologist has been thorough.  I also see a gastroenterologist and have had several test that all show no reflux, spasm, or any inflamation.  I tried proton pump inhibitors, but they didn't help and I didn't tolerate the side effects.

The cough only seems to come after I have had the pain.  a reflex type of cough.  nonproductive. almost like my lungs are filled with fluid (from aspiration).   I did see a pulmonology spec and she ruled out asthma.

could I be having a problem with my valves that didn't show up during tests?  like when i am running?    when I try to run hard (like in a race)  I have skipped beats or PVC's?  

thanks,

Marti