The prognostic value of deep earlobe creases in patients with acute ischemic stroke

Background and purpose

Data on earlobe crease (ELC) among patients with acute ischemic stroke (AIS) are limited. Here, we determined the frequency and characteristics of ELC and the prognostic effect of ELC among AIS patients.

Methods

A total of 936 patients with acute AIS were enrolled during the period between December 2018 and December 2019. The patients were divided into those without and with ELC, unilateral and bilateral ELC, and shallow and deep ELC, according to the photographs taken of the bilateral ears. Logistic regression models were used to estimate the effect of ELC, bilateral ELC, and deep ELC on poor functional outcomes at 90 days (a modified Rankin Scale score ≥2) in AIS patients.

Results

Among the 936 AIS patients, there were 746 (79.7%) patients with ELC. Among patients with ELC, there were 156 (20.9%) patients with unilateral ELC and 590 (79.1%) with bilateral ELC and 476 (63.8%) patients with shallow ELC and 270 (36.2%) with deep ELC. After adjusting for age, sex, baseline NIHSS score, and other potential covariates, patients with deep ELC were associated with a 1.87-fold [odds ratio (OR) 1.87; 95% confidence interval (CI), 1.13-3.09] and 1.63-fold (OR 1.63; 95%CI, 1.14-2.34) increase in the risk of poor functional outcome at 90 days in comparison with those without ELC or shallow ELC.

Conclusion

ELC was a common phenomenon, and eight out of ten AIS patients had ELC. Most patients had bilateral ELC, and more than one-third had deep ELC. Deep ELC was independently associated with an increased risk of poor functional outcome at 90 days.

Presence of ear lobe crease may predict intermediate and high-risk patients with acute non-ST elevation acute coronary syndrome

Introduction: Ear lobe crease (ELC) was first described in 1973 as a physical examination finding indicating significant coronary artery disease (CAD). Several studies have been carried out in relation to this finding, and it has been shown that it is a marker of intima-media thickness, carotid artery disease, and CAD. We aimed to investigate the relationship between earlobe crease, which is a simple physical examination finding, and GRACE score as a risk estimation index in acute coronary syndromes without ST-segment elevation (NSTE-ACS) patients.

Methods: 360 patients (mean age 62.2 years, 70% male) were included in our study. Patients were divided into two groups of GRACE scores ≤ 109 and >109, 167 patients were enrolled in group 1, and193 cases in group 2.

Results: The group 2 patients were older, had higher systolic blood pressure (SBP) levels, a higher rate of hypertension, higher glucose levels, lower creatinine clearance levels, higher initial and peak troponin levels, lower hemoglobin levels, lower left ventricular ejection fraction (LVEF) and higher Gensini scores than the patients in group 1. The higher GRACE score group had markedly increased frequencies of ELC compared to the lower GRACE score group (80.8% vs. 24.5%, respectively, P < 0.001).

Conclusion: The presence of ELC may predict moderate to high risk group of patients with NSTEACS.

Prevalence and clinical characteristics of earlobe crease in systemic sclerosis: Possible association with vascular dysfunction

Patients with systemic sclerosis (SSc) develop various vasculopathy-induced vascular disorders such as Raynaud's phenomenon, abnormal nail-fold capillaries, persistent digital ischemia, digital ulcers (DU), and sometimes develop renal crisis and pulmonary artery hypertension (PAH), affecting prognosis. Earlobe crease (ELC), also known as Frank's sign, is a wrinkle extending from the tragus to the outer border of the earlobe and is generally recognized as the sign of cardiovascular events. However, no previous study analyzed the association between ELC and SSc. In this study, we examined the prevalence and clinical characteristics of ELC in SSc patients. We analyzed 145 Japanese SSc patients and found that the prevalence of ELC in SSc patients was 23.4% (43/145), similar to that previously reported in the general population without SSc. Using univariate analysis, we found that SSc patients with ELC were characterized by old age, high incidence of DU, ILD and PAH, and high complication of coronary artery diseases (CAD) compared with SSc patients without ELC. In multivariate analysis, ELC was significantly associated with old age and incidence of DU. PAH tended to correlate with ELC without statistical significance. These results suggest that ELC may be associated with vascular disorders in SSc patients. This is the first report concerning the prevalence and clinical characteristics of ELC in patients with SSc. ELC is very easy to detect in clinical practice and helps physicians to identify SSc patients at risk of developing vascular disorders such as DU and PAH.

Morphological overview of cardiovascular comorbidities in chronic obstructive pulmonary disease: Frank's sign

OBJECTIVE

Cardiovascular diseases are the most common and important comorbidities in patients with chronic obstructive pulmonary disease (COPD). Literature indicates that there may be a relationship between diagonal earlobe crease (DELC) and coronary artery disease (CAD). Accordingly, the present study aimed to assess the relationship with DELC and cardiac comorbidities in patients with COPD during routine physical examination.

MATERIALS AND METHODS

In this prospective cohort study, we evaluated the demographic data, pulmonary function test (PFT) results, lipid profile, oxygen saturation, and the presence of DELC in patients with COPD and control subjects.

RESULTS

DELC was diagnosed in 155 (62%) of COPD patients and these patients had a higher prevalence of CAD (p = 0.044). Moreover, DELC was diagnosed in 135 men (68.5%) and 20 (37.7%) women in the COPD group (p<0.001) and in 39 (48.8%) men and 14 (56.0%) women in the control group (p = 0.527). On the other hand, CAD was diagnosed in 18% of patients with early-stage COPD (n = 104) and in 30.8% of patients with late-stage COPD (n = 146) (p = 0.041). The sensitivity and specificity of DELC positivity in predicting CAD were 80.65% and 44.15% in COPD patients, respectively.

CONCLUSION

The presence of cardiac comorbidities in COPD patients may play a vital role in the severity of the disease, exacerbations, and may also reduce the treatment response. Accordingly, an earlobe examination of patients with COPD may be useful in predicting the presence of cardiac comorbidities with high sensitivity.

On the association between earlobe crease and the carotid intima-media thickness: A population-based study

The earlobe crease (ELC) has been linked to coronary artery disease, but there is limited information on the association between ELC and extracranial atherosclerosis. Using the Atahualpa Project cohort, we aimed to assess the association between ELC and increased carotid intima-media thickness (cIMT). Atahualpa residents aged ≥40 years underwent visual inspection of both earlobes to evaluate ELC presence, and ultrasound examinations of carotid arteries to calculate the cIMT. The association between both variables was assessed by logistic regression and predictive models, after adjusting for relevant confounders. Mean age of 570 enrolled individuals was 61.5 ± 12.4 years (58% women). ELC was present in 221 (39%) participants. The mean cIMT was 0.85 ± 0.19 mm, with 81 individuals (14%) having an increased cIMT (>1 mm). Univariate logistic regression showed a significant association between ELC presence and increased cIMT (OR: 1.67; 95% C.I.: 1.04-2.69), which disappeared when age (OR: 1.09; 95% C.I.: 0.65-1.85) and other covariables (OR: 1.06; 95% C.I.: 0.62-1.84) were added to the model. Predictive cIMT margins did not differ according to ELC presence or absence, with participants stratified in quartiles of age. This study shows that the effect of the increase in cIMT in subjects with ELC is related to aging.

Diagonal Earlobe Crease, a Marker of Coronary Artery Disease: A Case Report on Frank's Sign

There are various physical signs that can be used as a reliable tool to diagnose the subclinical stages of atherosclerosis, including corneal arcus, xanthelasma, and diagonal earlobe crease (DELC) or “Frank's sign”. Bilateral diagonal earlobe crease has been positively correlated with coronary artery disease (CAD) and peripheral vascular disease (PVD). The presence of DELC has been identified as an independent variable for CAD. The exact etiology is unknown and the association between the presence of DELC and coronary artery disease (CAD) still remains controversial. We report a case of a patient with bilateral DELC who was found to have remarkable non-occlusive CAD on diagnostic coronary angiography.

The Association between Earlobe Crease (Frank's Sign) and Abnormal Ankle-Brachial Index Determination Is Related to Age: A Population-Based Study

Background

Information on the association between earlobe crease (ELC) and peripheral artery disease is limited. We assessed this association in community-dwelling older adults.

Study Design

A total of 294 Atahualpa residents aged ≥60 years were enrolled. ELC were visually identified by two raters. The ankle-brachial index (ABI), used as a surrogate of peripheral artery disease, was categorized using American Heart Association criteria. Using logistic regression and probability models, adjusted for demographics and cardiovascular risk factors, we assessed the relationship between ELC and abnormal ABI determinations, as well as the influence of age on this association.

Results

ELC was identified in 141 (48%) individuals, and abnormal ABI determination was carried out in 56 (19%). The association between ELC and abnormal ABI was nonsignificant in logistic regression and probability models with individuals stratified according to their median age.

Conclusions

The association between ELC and abnormal ABI determinations is probably attenuated by the high prevalence of both conditions in older persons. ELC might not be useful for identifying candidates for ABI determination.

Association Between the Frank Sign and Cardiovascular Events

Clinicians have attempted to find early preclinical physical diagnosis signs to detect vascular diseases at the preclinical stage and to prevent clinical deterioration in time. An interesting example of such signs is the Frank sign, which was first described by Dr Sonders T. Frank in 1973. Our goal was to summarize the clinical trials and observational studies that had examined the association between the Frank sign and cardiovascular diseases. Summarizing the 57 studies we found showed that this association could be used for early diagnosis of coronary and vascular diseases in the preclinical stage and that they were found in different populations around the world. Autopsy studies also found a strong association between the Frank sign and cardiovascular causes of death in both sexes. Cardiovascular causes of death included ischemic and hypertensive heart disease, calcific valvular stenosis, ruptured dissecting aneurysm of the thoracic aorta, and ruptured atheromatous aneurysm of the abdominal aorta. The Frank sign was correlated with increased intima-media thickness and stroke and was found in patients with peripheral vascular disease and with cardiovascular risk factors. The Frank sign could serve as a physical sign to help clinicians diagnose cardiovascular diseases.

Diagonal Earlobe Crease (Frank's Sign): A Predictor of Cerebral Vascular Events

BACKGROUND

Frank's sign was first described in 1973 by an American physician (Sonders T. Frank). It is a diagonal crease in the earlobe that starts from the tragus to the edge of the auricle in an angle of 45° in varying depths. Frank's sign was described as a predictor of future coronary heart disease and peripheral vascular diseases. The aim of the study was to examine the association between Frank's sign and the development of ischemic stroke.

METHODS

This was a prospective study that enrolled consecutive patients admitted with an acute ischemic stroke. Frank's sign was tested in both ears. Clinical data included age, gender, type 2 diabetes mellitus, and hypertension. The study was approved by the institutional review board (the institutional ethics committee).

RESULTS

A total of 241 consecutive patients who were hospitalized with an acute stroke and were eligible to take part in the study were recruited. Frank's sign was present in 190 patients (78.8%). Patients were divided according to clinical findings and the findings from brain computed tomography. There were 153 patients with transient ischemic attacks (63.6% of the patients) and 88 with cerebrovascular accidents (36.4% of the patients). A total of 112 patients with transient ischemic attacks had Frank's sign (73.2%), and 78 patients with cerebrovascular accidents had Frank's sign (88.6%), with a statistically significant difference (P <.01).

DISCUSSION

Frank's sign could predict ischemic cerebrovascular events. Patients with classical cardiovascular risk factors had Frank's sign at a higher frequency.

Diagonal Earlobe Crease is a Visible Sign for Cerebral Small Vessel Disease and Amyloid-β

We investigated the frequency and clinical significance of diagonal earlobe crease (DELC) in cognitively impaired patients using imaging biomarkers, such as white matter hyperintensities (WMH) on MRI and amyloid-β (Aβ) PET. A total of 471 cognitively impaired patients and 243 cognitively normal (CN) individuals were included in this study. Compared with CN individuals, cognitively impaired patients had a greater frequency of DELC (OR 1.6, 95% CI 1.1–2.2, P = 0.007). This relationship was more prominent in patients with dementia (OR 1.8, 95% CI 1.2–2.7, P = 0.002) and subcortical vascular cognitive impairment (OR 2.4, 95% CI 1.6–3.6, P < 0.001). Compared with Aβ-negative cognitively impaired patients with minimal WMH, Aβ-positive patients with moderate to severe WMH were significantly more likely to exhibit DELC (OR 7.3, 95% CI 3.4–16.0, P < 0.001). We suggest that DELC can serve as a useful supportive sign, not only for the presence of cognitive impairment, but also for cerebral small vessel disease (CSVD) and Aβ-positivity. The relationship between DELC and Aβ-positivity might be explained by the causative role of CSVD in Aβ accumulation.

Relation of the Bilateral Earlobe Crease to Endothelial Dysfunction

The presence of an earlobe crease (ELC) may be a simple sign to predict atherosclerosis. We evaluated the relation between ELC and vascular function. We measured flow-mediated vasodilation (FMD) and nitroglycerine-induced vasodilation (NID) and observed bilateral earlobes in 400 consecutive subjects. At first, the subjects were divided into 3 groups: non-ELC group, unilateral ELC group, and bilateral ELC group. FMD and NID were significantly lower in the unilateral and bilateral ELC groups than those in the non-ELC group. After adjustment of cardiovascular risk factors, bilateral ELC, but not unilateral ELC, was associated with lower FMD and lower NID. We also investigated whether an increase in the number of ELCs worsens endothelial function, whether the difference in ELC structure (cross stripes and/or ramification) affects endothelial function, and whether endothelial function is impaired in subjects with superficial wrinkles depending on age. The number of ELCs, shape of the ELC, and superficial wrinkles were not associated with endothelial dysfunction. In conclusion, these findings suggest that the presence of bilateral ELCs is associated with vascular dysfunction.

Anterior Tragal Crease Is Associated With Atherosclerosis: A Study Evaluating Carotid Artery Intima-Media Thickness

The utility of the ear crease sign, anterior tragal crease (ATC), as a marker of atherosclerosis is yet to be established. The intima-media thickness of the common carotid artery (IMT-CCA) has been used as a noninvasive surrogate marker for atherosclerosis. History of traditional risk factors for atherosclerosis was obtained from 147 volunteers; ear examination was also performed and venous blood was drawn for laboratory analysis. The volunteers then underwent an ultrasonography measurement of the IMT-CCA. In univariate analysis, presence of ATC, age, underlying hypertension, diabetes mellitus, ischemic heart disease, cerebrovascular disease, cigarette smoking, low-density lipoprotein, and high-sensitivity C-reactive protein were significantly associated with the IMT-CCA. Further multivariate analysis confirmed a significant association between the presence of ATC and IMT-CCA, when adjusted for other factors (adjusted β_ATC = .010, 95% confidence interval: 0.0021-0.019). Anterior tragal crease is a potential clinical sign that can predict atherosclerosis. The sign is easily recognizable and may help health-care professionals to identify those at risk of atherosclerosis, especially in people with no clinical signs of the disease.

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.

Earlobe crease shapes and cardiovascular events

Earlobe crease (ELC) has been linked to coronary artery disease; however, systematic evaluations of the earlobe and its relation to ischemic stroke are lacking. The objectives were to define the ELC using a single-blind approach and to determine through multivariate analysis its association with cardiovascular events (CVEs) comprising coronary, ischemic cerebrovascular, and peripheral vascular diseases. A single-blind cross-sectional study was performed in 2 phases: (1) an initial study (n = 300) to define ELC classification criteria and (2) a confirmation stage (n = 1,000) to analyze ELC association with CVEs. Each of the participants' pinnae were photographed and classified blindly by joint decision according to ELC's inclination, length, depth, and bilateralism. Patients' medical histories were reviewed for age, cardiovascular risk factors, and CVEs. The concordance rate after the classification of all photographs was 89.6%. The first phase did not find any correlation between the different depth degrees or vertical creases and CVEs. The second stage concluded that diagonal bilateral ELC prevalence in patients with CVEs was 43% compared with 29% in the control patients (p <0.001). The multivariate analysis showed an association between ELC and CVEs (odds ratio 1.45, 95% confidence interval [CI] 1.08 to 1.93, p = 0.012), with a sensitivity and specificity of 43% and 70%, respectively. Ischemic stroke alone was also associated with diagonal bilateral ELC (odds ratio 1.67, 95% confidence interval 1.1 to 2.51, p = 0.015). In conclusion, diagonal bilateral ELC is independently associated with CVEs in the hospitalized population. An independent association with ischemic stroke has also been demonstrated for the first time.