Does This Patient Have Aortic Regurgitation?

CLINICAL SCENARIO You are asked to see a 59-year-old woman with liver cirrhosis who will be undergoing sclerotherapy for esophageal varices. When she was examined by her primary care physician, she had a pulse pressure of 70 mm Hg. The primary care physician is concerned about the possibility of aortic regurgitation (AR) and asks you whether endocarditis prophylaxis is necessary for sclerotherapy. You conduct a complete physical examination and hear no early diastolic murmur in the third or fourth intercostal spaces at the left-sternal border. You feel that the patient is unlikely to have AR and that endocarditis prophylaxis is not needed. You suspect that the wide pulse pressure is a peripheral hemodynamic consequence of cirrhosis, not AR. The primary care physician, however, wonders whether the procedure should be delayed until an echocardiogram can be obtained.