The ear lobe crease sign and coronary artery disease in aortic stenosis

Diagonal Earlobe Crease (Frank's Sign) for Diagnosis of Coronary Artery Disease: A Systematic Review of Diagnostic Test Accuracy Studies

Coronary artery disease is a global challenge for healthcare systems. Early diagnosis is a key issue to improve quality of life and reduce morbidity and mortality. Diagonal earlobe crease, a wrinkle extending obliquely across the earlobe, was linked by many authors to various atherosclerotic diseases. This systematic review aimed at summarizing the diagnostic accuracy of diagonal earlobe crease for diagnosis of chronic and acute coronary syndromes in adults. Cochrane's recommendations for systematic reviews of diagnostic test accuracy studies were followed. The protocol was registered on PROSPERO. Seven electronic databases were searched up to April 2021. The risk of bias and applicability were assessed using the QUADAS-2 tool. Meta-analysis was not performed. Finally, 13 cross-sectional studies evaluating 3951 patients were analyzed, all of which focused on chronic coronary syndromes defined as anatomically significant coronary stenosis. Invasive coronary angiography was used as a reference in most studies, except one which utilized computed tomography angiography. Sensitivity ranged from 26% to 90%, and specificity from 32% to 96%. Positive likelihood ratios varied from 1.11 to 7.03, but most results were below 2. Negative likelihood ratios were from 0.84 to 0.30, but most values exceeded 0.5. Diagnostic accuracy of diagonal earlobe crease for the detection of chronic coronary syndromes is insufficient. It only slightly changes pre-test probability, and its mere presence or absence should not affect the clinical management of the patients. However, for its feasibility and easy interpretation, Frank's sign could be considered as a part of physical examination.

Diagonal Earlobe Crease as a Significant Marker for Coronary Artery Disease: A Case-control Study

Objectives:

To investigate the association between diagonal earlobe crease (DELC) and coronary artery disease (CAD). Limited data exists in South Asia and no prior studies have been performed in Pakistan to assess this relationship.

Methods:

In this case-control study, 200 participants from December 2015 to March 2016 at Shifa International Hospital, Islamabad, Pakistan were enrolled. Consecutive non-probability sampling was used to recruit patients. Cases were enrolled from cardiac care unit (CCU) of the hospital with angiography-proven CAD. Controls were selected from surgical, medical and neurology units of the hospital if they had no previously established evidence or symptoms of CAD. Patients were evaluated in terms of age and any history of hypertension, diabetes and/or smoking. Cases and controls were examined separately by two investigators for the unilateral or bilateral presence of DELC of the lobular portion of either auricle. Patients with ear piercings were excluded from the study. The data was analyzed in statistical product and service solutions (SPSS) (IBM, Delaware, Chicago), and an online statistical software.

Results:

Out of the 200 patients, 126 (63%) were males and 74 (37%) were females. In the 100 cases, 76 had DELC and 24 had no crease whereas, among the 100 controls, 36 had DELC and 64 had no DELC (p <0.001, OR = 5.63, CI = 2.91-10.93). The prevalence of diseases such as hypertension, diabetes, smoking among the cases and controls were 66%, 53%, 27% and 27%, 18%, 25% respectively. The effect of hypertension and diabetes on the presence of DELC was statistically significant (p <0.05) but the impact of smoking on DELC presence was insignificant (p >0.05).

Conclusion:

There is a significant association between DELC and CAD. This is the first case-control study from South Asia disclosing this important correlation. Our study also reports a high frequency of DELC in patients suffering from hypertension and diabetes mellitus. No association between smoking and DELC was found.

Ear lobe crease: a marker of coronary artery disease?

The ear lobe crease (ELC) has been defined as a deep wrinkle that extends backwards from the tragus to the auricle. It has been proposed that ELC is a predictor of coronary artery disease (CAD). In this review, we consider the possible association between ELC and CAD. Our aim is to systematically address all the relevant evidence in this field. There are many studies that support an association between ELC and CAD. However, other studies did not find such an association. A recent meta-analysis supports the hypothesis that ELC could be a marker of CAD. However, several limitations raise doubts as to whether we should accept this link.

The earlobe crease, coronary artery disease, and sudden cardiac death: an autopsy study of 520 individuals

The majority of previous studies have demonstrated a correlation between diagonal earlobe creases (ELC) and coronary artery disease (CAD). In this study of 520 forensic autopsy cases, the earlobes were studied and photographed before autopsy, and the existence of a diagonal ELC was noted in 55%. The cause of death, the degree of coronary atherosclerosis, aortosclerosis, and cerebrosclerosis, as well as heart, kidney, and spleen weights, were noted in each case. The body mass index (BMI), thickness of abdominal fat, baldness, and excessive hair in the meatus externa of the external ears were also assessed. Nonparametric methods were used in the statistical calculations. It was found that ELC was strongly correlated with CAD in both men and women (P < 0.0001) but with sudden cardiac death (SCD) only in men (P < 0.04). The sensitivity of the ELC sign was 75% and the positive predictive value (ppv) was 68%. In individuals below 40 years, the ppv was as high as 80%. Using multiple logistic regression analysis, ELC was found to be the strongest independent risk factor for CAD and SCD apart from age and BMI (both genders), as well as baldness and hair in the meatus externa (in males). It is concluded that in a patient population similar to that in the present study the ELC sign could be especially useful in screening for premature CAD in younger individuals.

Associação entre doença arterial coronariana e as pregas lobular diagonal e anterotragal em homens

FUNDAMENTOS: Diversas alterações dermatológicas foram associadas à doença arterial coronariana, representando achados de fácil constatação que podem contribuir na estratificação não invasiva do risco cardíaco. OBJETIVOS: Avaliar comparativamente a prevalência de certos achados dermatológicos em pacientes com ou sem doença arterial coronariana. MÉTODOS: Estudo caso/controle envolvendo pacientes do sexo masculino submetidos à cineangiocoronariografia. Foram considerados aqueles casos com obstrução de mais de 50% em pelo menos uma coronária. Avaliou-se a presença da prega lobular diagonal, prega anterotragal, alopecia e presença de pêlos no tórax nos dois grupos. Os resultados foram ajustados para os fatores de risco: tabagismo, hipertensão, diabetes, idade, dislipidemia e índice de massa corporal. RESULTADOS: Analisaram-se 110 pacientes (80 casos e 30 controles). A prevalência da prega lobular diagonal nos casos (60,0%) foi maior do que no grupo controle (30,0%) (p<0,05). Alopecia androgenética e distribuição de pêlos no tórax não demonstraram associação positiva com coronariopatia neste estudo. O Odds Ratio (IC 95%), da prega lobular diagonal foi de 3,1 (1,2-8,3) e para prega anterotragal foi de 5,5 (1,9-16,3). A verificação simultânea da prega lobular diagonal e prega anterotragal representou valor preditivo positivo de 90%. CONCLUSÕES: Detectou-se associação positiva entre a presença da prega lobular diagonal bilateral e prega anterotragal bilateral com doença arterial coronariana, sendo que a presença simultânea das duas pregas apresenta alta preditividade para doença arterial coronariana.

Diagonal earlobe creases and prognosis in patients with suspected coronary artery disease

PURPOSE

To determine whether high-risk patients with unilateral, bilateral, or no earlobe creases (ELC) have different prognoses for common sequelae of coronary heart disease.

PATIENTS AND METHODS

Two hundred sixty-four consecutive patients from a university-based coronary care unit or catheterization laboratory were blindly followed up for 10 years, using questionnaires, medical records, and death certificates. The primary outcome measure was time to cardiac event; namely, coronary artery bypass graft (CABG), myocardial infarction (MI), or cardiac death. Analyses included log-rank tests and Cox proportional hazards regression modelling.

RESULTS

The number of creased ears was significantly associated, in a graded fashion, with 10-year cardiac event free survival: 43.5% +/- 5.7%, 33.0% +/- 6.7%, or 17.5% +/- 4.6% (mean +/- standard error for 0, 1 or 2 ELC, respectively; P = 0.003). After adjustment for 10 known cardiac risk factors, including age and left ventricular ejection fraction, the relative risk for a cardiac event for a unilateral ELC, relative to 0 ELC, was 1.33 (95% confidence interval [CI] 1.10 to 1.61, P = 0.02), and for bilateral ELC, it was 1.77 (95% CI 1.21 to 2.59, P = 0.003).

CONCLUSIONS

Ear lobe creases are associated, in a graded fashion, with higher rates of cardiac events in patients admitted to hospital with suspected coronary disease. In such patients, ELC may help to identify those at higher risk for sequelae for coronary disease.

Increased all-cause and cardiac morbidity and mortality associated with the diagonal earlobe crease: a prospective cohort study

PURPOSE

To ascertain whether the diagonal earlobe crease (ELC) is associated prospectively with future death or cardiac events over 8 years of follow-up in two sets of patients: those with known coronary artery disease (CAD) and those without evidence for CAD.

PATIENTS AND METHODS

We performed a prospective, observational study of 108 patients in four cohorts (each matched for age, sex, and race, but differing in the presence or absence of both a diagonal ELC and CAD in 1979 to 1982). Follow-up information was gathered by telephone interviews, and dates and causes of death were determined by reference to death certificates (n = 48), hospital records (n = 9), or attending physician statements (n = 1).

RESULTS

During 8 to 10 years of follow-up, 58 of the patients had died. Patients with ELCs had poorer survival rates than those without creases, by stratified log-rank test (p = 0.006 for the cohorts thought not to have CAD, and p = 0.058 for those with CAD). Cardiac death rates (due to acute myocardial infarction, "sudden cardiac death," or heart failure) were also higher for patients with ELCs: 8.0 versus 0.9 cardiac deaths per 100 patient-years (p less than 0.001) in patients without CAD at entry, and 11.7 versus 3.7 cardiac deaths per 100 patient-years (p = 0.008) in patients with CAD in 1979 to 1982. Cardiac event rates (cardiac death, nonfatal myocardial infarction, or coronary artery bypass surgery) were also higher in those with ELCs: 10.4 versus 1.4 events per 100 patient-years (p less than 0.001) for those without known CAD, and 15.8 versus 5.7 events per 100 patient-years (p = 0.009) for those with CAD.

CONCLUSION

These results suggest that a diagonal ELC is associated with increased all-cause and cardiac morbidity and mortality. Patients with ELCs may be at higher risk for coronary events, and might be especially cautioned to control or reduce other cardiac risk factors, even if currently without diagnostic evidence of CAD.