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A Brief History: Frank’s Sign

In 1973, a physician called Sanders T. Frank had a letter published in the New England Journal of Medicine describing 20 of his patients with an earlobe crease, who were under 60 years old, with angina (chest pain) and proven coronary artery blockages. This study was the first to describe such a possible association between heart disease and an earlobe crease. However, there was no normal group to compare this to, making it scientifically inconclusive. Since then numerous studies, including those with control groups, have backed up the association. But what does all this mean? When determining associations we need to ask a number of important questions. 1) Does the data support a true association of an earlobe crease and heart disease? 2) If there is an association, is this just due to the fact that the earlobe crease is associated with already established risk factors for heart disease? 3) Is the presence of an earlobe crease independently associated with heart disease? 4) If there is an association, what is the explanation?

Most Medical Studies Show There is an Association

After the initial report in 1973, a number of other reports surfaced. In the 1970’s-1990’s many studies reported the existence of an earlobe crease was more common in those having had a heart attack as compared to those that hadn’t. Some smaller studies have even looked at the predictive significance of an earlobe crease. One study followed 108 people and reported that patients with an earlobe crease were more likely to have cardiac events than those without. This was reinforced by larger studies looking at the same topic.

Autopsy studies have also been conducted to investigate this association. Studies from the UK demonstrated that those with earlobe creases were almost twice as likely to have coronary disease. A study from Sweden showed similar findings. One recent study of 450 Chinese people demonstrated that in those undergoing angiography for the investigation of heart disease, around ½ of those without significant blockages had earlobe crease, whereas ¾ of those with significant blockages had a visible earlobe crease. Another similarly designed study with Turkish participants demonstrated that earlobe crease was associated with risk factors for cardiovascular disease and the presence of coronary artery disease. The association remained, even when accounting for the effects of the risk factors suggesting that earlobe crease was independently associated with heart disease.

It’s important to note there are studies that did not show any association between having an earlobe crease and cardiovascular outcomes or the presence of coronary artery disease. Many of these studies had several hundred patients and showed that the proportion of people with cardiovascular disease was similar in both groups. One of the studies concluded that earlobe crease is more likely with advancing age, and it is in fact age that drives the association.

A True Correlation, Not Just a Chance Finding

It was thought however that the earlobe crease was associated with coronary artery disease only because it was also associated with the presence of other risk factors such as smoking, diabetes, obesity and blood pressure amongst others. Studies then began to emerge suggesting that the presence of earlobe crease was independently associated with the presence of coronary disease.

The largest study to date, and probably the most powerful was reported this year. Almost 11,000 Danish participants were followed for up to 35 years. All participants were free of known coronary artery disease at the beginning of the study. The study found having an earlobe crease was significantly associated with an increased risk of developing clinically significant heart disease. The chance of having a heart attack, or ST-segment elevation myocardial infarction, also rose among the people who had a defined earlobe crease. These associations were found to be independent of other, well-established cardiovascular risk factors.

Was Emperor Hadrian’s Earlobe Crease the Cause of His Demise?

The presence of a diagonal earlobe crease has also been associated with the death of Emperor Hadrian who was believed to die from coronary artery disease and heart failure. It was noted that both the bust of Hadrian in Greek and Italian museums had clear earlobe creases.

Why Would Having an Earlobe Crease be Associated with Heart Disease?

It was initially thought that earlobe creases and heart disease would occur together, as both are supplied by end-arteries without the chance for other arteries to take over blood supply when damage occurred. Some studies suggest that the processes that underlie aging – such as elastic tissue degeneration, microvessel damage and intracellular ageing – are the same that are responsible for the development of earlobe creases. Supporting this is the fact that the earlobe crease is only rarely seen in children. Unfortunately, there is no one convincing mechanism.

Conclusion: What to Make of It All

Taken in conjunction, most of the studies conducted clearly show an association between earlobe creases and heart disease. In fact, most studies – including the larger ones – suggest that this association is true and conclude the association cannot be explained by other risk factors. Unfortunately, although research supports an association as of yet we don’t have a convincing explanation as to why earlobe crease would be associated with heart disease.

The modern day approach to detecting heart disease has likely limited the usefulness of Frank’s sign. Although the earlobe crease may be associated with coronary artery disease (CAD), its sensitivity for detecting this is nowhere near that of stress tests, CT scores, or angiograms. The presence of the earlobe crease may be used to identify those who are at higher risk and should therefore have close attention paid to the presence of risk factors such as blood pressure and cholesterol. If you have an earlobe crease, don’t panic. Instead, adopt a proactive approach to the prevention of coronary heart disease such as a healthy diet, prevention of diabetes, active lifestyle and other measures to prevent the onset and progression of coronary disease.

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