Looks Like the Ear Lobe Crease is Here to Stay
Abstract & Commentary
By Harold L. Karpman, MD, FACC, FACP, Clinical Professor of Medicine, UCLA School of Medicine. Dr. Karpman reports no financial relationships relevant to this field of study.
Synopsis: In this study of patients imaged with CT angiography, finding of the presence of diagonal earlobe creases was independently and significantly associated with increased prevalence, extent, and severity of coronary artery disease.
Source: Shmilovich H, et al. Relation of diagonal ear lobe crease to the presence, extent, and severity of coronary artery disease determined by coronary computed tomography angiography. Am J Cardiol 2012;109:1283-1287.
The diagonal ear lobe crease (DELC) is a wrinkle-like line extending diagonally from the tragus across the lobule to the rear edge of the auricle of the ear, and its presence has been demonstrated not to be related to sleeping position or wearing earrings. Over the years, it has been intermittently associated with coronary artery disease (CAD), and is referred to as the "Frank" sign because of an article published by Frank in 1979,1 in which he first associated the presence of the DELC with CAD. The association has remained controversial with some published papers supporting the observation2-4 and other studies disputing it.5-6
Shmilovich and his colleagues performed a study intended to assess whether the presence of DELC correlates to the presence, extent, and severity of CAD as determined by coronary computed tomography (CT) angiography.7 They studied 430 consecutive patients without a history of coronary artery intervention who underwent CT angiography on a dual-source CT scanner. The presence of DELC was confirmed in the individual patients by two blinded observers, and the CT angiography images were interpreted by two blinded readers who evaluated the CT angiograms for the presence of CAD and for significant (i.e., defined as > 50% stenosis) CAD narrowing. Multivariable logistic regression was performed to adjust for CAD confounders including age, gender, symptoms, and CAD risk factors. In this study of patients imaged with CT angiography, finding DELC was independently and significantly associated with increased prevalence, extent, and severity of CAD.
Commentary
Over the many years since the relationship between DELC and CAD was described, many concerns have surfaced regarding the different and varying definitions of CAD.3 For example, in some instances, the diagnosis of CAD was made solely by determining the presence of significant risk factors and/or electrocardiographic abnormalities at rest. Necropsy studies have supported the association between DELC and CAD finding that the presence of DELC often predicted coronary artery plaques causing more than 75% luminal stenosis.8-12 As a result of these multiple studies, some observers have even recommended that observing DELC to be present should be used as a screening tool for atherosclerosis in young patients.10 It must be carefully recognized that despite the many published papers, a definite pathophysiologic explanation for this association has not been ascertained. It had been suggested that the presence of DELC is linked to atherosclerosis by common genetic factors,3 that it may be an acquired physical sign due to vascular disease, skin atrophy, or changes in connective tissue matrix,3 or is due to the loss of elastin and elastic fibers reflecting microvascular disease in the coronary bed.13,14 Some authors have concluded that the presence of DELC predicts all-cause and cardiac-cause morbidity and mortality and is associated with a lower 10-year cardiac event-free survival rate.15 The data from the Shmilovich study support the concept that increased CAD risk in subjects with DELC may be associated with a greater underlying CAD burden in these patients for uncertain reasons.7
Although the reasons for the association between DELC and CAD remain unclear, the Shmilovich study7 is the first study using the robustly validated power of CT angiography to identify the presence and severity of CAD in subjects with DELC. This finding of an association between DELC and significant CAD would suggest that clinicians should take a moment to examine their patients for DELC and should even consider screening patients in the younger age groups. The finding of DELC in asymptomatic patients with a low cardiovascular risk profile may lead to more intensive evaluation of these patients for occult CAD, which could lead to much earlier and effective CAD preventive therapy.
References
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2. Elliott WJ. Ear lobe crease and coronary artery disease. 1000 patients and review of the literature. Am J Med 1983;75:1024-1032.
3. Evrengul H, et al. Bilateral diagonal ear lobe crease and coronary artery disease: A significant association. Dermatology 2004;2009:271-275.
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5. Davis TM, et al. The diagonal ear lobe crease (Frank's sign) is not associated with coronary artery disease or retinopathy in type II diabetes; the Fremantle Diabetes Study. Aust NZ J Med 2000;30:573-577.
6. Motamed M, et al. The predictive value of diagonal earlobe crease sign. Int J Clin Pract 1998;52:305-306.
7. Shmilovich H, et al. Relation of diagonal ear lobe crease to the presence, extent, and severity of coronary artery disease determined by coronary computed tomography angiography. Am J Cardiol 2012;109:1283-1287.
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14. Shoenfeld Y, et al. Diagonal earlobe crease and coronary risk factors. J Am Geriat Soc 1980;28:184-187.
15. Elliott WJ, et al. Diagonal earlobe creases and prognosis in patients with suspected coronary artery disease. Am J Med 1996;100:205-211.