The relationship of diagonal earlobe crease (Frank's sign) and obstructive coronary artery disease in patients undergoing coronary angiography

BACKGROUND

Traditional risk factors for cardiovascular disease (CVD) play an important role in the clinical evaluation of patients with symptoms suggestive of coronary artery disease (CAD). The utility of the diagonal earlobe crease (DELC) in predicting the presence of CAD is controversial.

PURPOSE

To investigate the association between DELC, traditional CVD risk factors, and obstructive CAD.

METHODS

This prospective study included 1377 patients (mean age 65 ± 10 years, 64% male) who underwent invasive coronary angiography for suspected acute or chronic coronary syndromes. In addition to routine clinical assessment, all patients underwent visual examination of both earlobes for the presence of DELC. All assessments were made by three independent readers, with a majority vote in the case of disagreement. Obstructive CAD was defined by invasive coronary angiography as > 50% stenosis of the left main coronary artery or > 70% stenosis in any other major epicardial coronary artery.

RESULTS

Bilateral DELC was observed more frequently in patients with obstructive CAD than in those without it (67% vs. 33%, p = 0.022). In the multivariate logistic regression model, bilateral DELC was independently associated with CAD (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.07-1.74), along with smoking (OR 1.86, 95% CI 1.44-2.38), diabetes mellitus (OR 1.67, 95% CI 1.29-2.15), male sex (OR 2.04, 95% CI 1.61-2.58), and dyslipidemia (OR 1.54, 95% CI 1.12-2.30); however, the diagnostic accuracy of DELC was modest and resembled that of traditional CVD risk factors.

CONCLUSION

Despite being independently associated with obstructive CAD, DELC is not a reliable stand-alone clinical marker of CAD due to modest diagnostic accuracy.

The prognostic value of the Frank sign

Frank's sign (named after American pulmonologist Sanders T. Frank) refers to a diagonal skin fold between the tragus and outer edge of the earlobe. Gradation is based on the bilateral presence and/or degree of the earlobe fold. The presence of this sign, referred to as the diagonal earlobe crease (DELC), has been associated with coronary artery disease (CAD), independent of other cardiovascular risk factors. Corresponding studies are predominantly based on clinical or angiographic assessments, and few autopsy studies exist. The association of DELC with CAD, cardiovascular risk factors, and causes of death was investigated via retrospective and prospective evaluations. It was also investigated whether the degree of DELC correlated with the macroscopic severity of coronary heart disease. Furthermore, the influence of age on the appearance of DELC was analyzed and compared using two age groups. Additionally, binomial logistic regression analysis was performed to investigate the influence of age on the presence of higher-grade DELC and CAD. In cases related to a lethal cardiac event, the majority (78%) showed high-grade DELC. The DELC grade correlated significantly with CAD severity (r_s = 0.474, p < 0.001) and with the severity of general atherosclerosis (r_s = 0.606, p < 0.001) with medium and large effects sizes, respectively. Age was predominantly more suitable than DELC concerning the sensitivity, specificity, and positive prognostic value for preexisting cardiac disease and cardiac-related causes of death. In both DELC and CAD, age has a significant influence on the presence of higher-grade manifestation, but the influence of age in CAD appears to be even more significant than in DELC. The main results of previous autopsy studies and the prognostic value could have been confirmed, but these findings appear to be limited to younger patients.

Diagonal earlobe crease and long-term survival after myocardial infarction

Background

The association between the presence of a diagonal earlobe crease (DEC) and coronary artery disease has been prescribed earlier. However, it is unclear whether patients with acute myocardial infarction (AMI) and DEC have a higher risk of dying.

Methods

Study participants were persons with AMI who were included in the KORA Myocardial Infarction Registry Augsburg from August 2015 to December 2016. After taking pictures of both earlobes, two employees independently assessed the severity of DEC in 4°. For analysis, the expression of the DEC was dichotomized. Information on risk factors, severity and therapy of the AMI was collected by interview and from the medical record. Vital status post AMI was obtained by population registries in 2019. The relationship between DEC and survival time was determined using Cox proportional hazards models.

Results

Out of 655 participants, 442 (67.5%) showed DEC grade 2/3 and 213 (32.5%) DEC grade 0/1. Median observation period was 3.06 years (5–1577 days). During this period, 26 patients (12.2%) with DEC grade 0/1 and 92 patients (20.8%) with grade 2/3 died (hazard ratio 1.91, 95% confidence interval (CI) 1.23–2.96, p = 0.0037). In the fully adjusted model, patients with DEC grade 2/3 had a 1.48-fold increased risk of death compared to the DEC grade 0/1 patient group (CI 0.94–2.34, p = 0.0897). The fully adjusted model applied for 1-year survival revealed a significant, 2.57-fold hazard ratio of death (CI 1.07–6.17, p = 0.0347) for the patients with DEC grade 2/3.

Conclusions

Our results indicate that DEC is independently associated with 1-year AMI survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02425-4.

Frank's sign and paired ear creases of the helix : Current concepts of significance for morbidity

Frank's sign (FS) was described in 1973 as an auricular marker for cardiovascular disease presenting as a crease of the auricular lobule. Since its first clinical description, there have been multiple studies underlining the role of FS in a myriad of conditions, such as atherosclerosis, hypertension, cerebrovascular disease, peripheral artery disease, metabolic diseases as well as studies looking at physiological differences in the auricular shape that may mimic FS; however, a complex study to comprehensively analyze the clinical, gross, and histological findings of patients with FS has not yet been performed. Most studies focused on a specific system, mechanism of disease entry. This short review tries to summarize the current knowledge of FS in relation to diseases as well as its clinical classification, histology, and association with the recently described paired ear creases of the helix, as an attempt to reveal the dubious role of FS as a possible prognostic and predictive marker.

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.

The Histological Basis of Frank's Sign

Frank's sign is a diagonal crease of the ear lobe, supposedly related to cardiac pathology, and has strongly been associated with coronary artery atherosclerosis. A total of 45 consecutive adult patients referred for autopsy in a one-and-a-half-year period were extensively studied. Samples from both the ear lobes were obtained for histopathology, as well as cardiac samples from all four cardiac compartments. When compared patients with Frank's sign and those without it had no statistical difference in age (p = 0.0575). There was however a statistically significant increased cardiac weight (p = 0.0005), left ventricular wall thickness (p = 0.0002), and right ventricular wall thickness (p = 0.0043). Histopathology obtained from the ear lobes revealed myoelastofibrosis in an arterial vessel, located at the base of the crease, diffuse fibrosis, and Wallerian-like degeneration, with eosinophilic inclusions in the peripheral nerves. These changes suggest a time-related progression of the crease-associated changes. Our data suggest a significant correlation between the morphological changes of the myocardium and the presence of the ear lobe creases, with arterial myoelastofibrosis, Wallerian-like degeneration in peripheral nerves and deep tissue fibrosis found in the base of the crease.

Diagonal earlobe crease (Frank's sign) and increased risk of cerebrovascular diseases: review of the literature and implications for clinical practice

Diagonal earlobe crease (DELC) or Frank's sign is a diagonal crease in the earlobe that extends diagonally from the tragus to the edge of the auricle with an angle of approximately 45°. Although its presence increases with advancing age, several studies have shown an independent association between DELC and cardiovascular diseases as well as peripheral vascular diseases. DELC has also been demonstrated to increase the risk of cerebrovascular events (mostly ischaemic stroke), probably through atherosclerotic mechanisms. A systematic literature search was conducted using PubMed and Embase to identify studies investigating the relationship between DELC and the occurrence of cerebrovascular diseases. We identified 5 articles (1469 subjects included). Since the presence of DELC can be easily evaluated, patients with the Frank's sign should undergo a diagnostic workup to detect vascular risk factors and implement preventative therapies.