The Clinical Picture

Bilateral earlobe creases and coronary artery disease

Author and Disclosure Information



A 70-year-old man with hypertension and hypercholesterolemia presented to the emergency department after the acute onset of substernal, pressure-like chest pain while climbing a flight of stairs. His physical examination was normal, but he was noted to have bilateral diagonal earlobe creases (the Frank sign) (Figure 1), considered by some to indicate risk of coronary artery disease.1–5

Figure 1. Earlobe creases (the Frank sign) were noted bilaterally.

Electrocardiography showed atrial fibrillation with a ventricular rate of 149 beats per minute, ST-segment elevation in leads V1 and aVR, and ST-segment depression in leads V3 to V6, II, III, and aVF.

Urgent coronary arteriography showed severe coronary artery disease (Figure 2). Left ventriculography showed an ejection fraction of 50% with mild anterior wall hypokinesis. A drug-eluting stent was placed in the mid-left anterior descending artery. The patient tolerated the procedure well, and his chest pain resolved afterward.


Figure 2. In A, coronary angiography showed 80% stenosis of the mid-left anterior descending artery (red arrow), chronic total occlusion of the left circumflex artery (white arrow), and in B, mild to moderate diffuse atherosclerosis of the right coronary artery (arrows).

Sanders T. Frank, in 1973, first described a diagonal wrinkle-like line on the earlobe as a sign of coronary artery disease.1 Subsequently, autopsy studies suggested that deep bilateral earlobe creases could be an important sign of coronary atherosclerosis.2 Diagonal earlobe creases have been shown to be independently associated with increased prevalence, extent, and severity of coronary artery disease.3,4 They are also associated with major adverse cardiovascular events4 and ischemic stroke.5 The mechanism linking diagonal earlobe creases and atherosclerotic disease is not yet clear.

This patient’s presentation and evaluation remind us that bilateral earlobe creases may be useful to include in the clinical examination of patients with suspected coronary artery disease and may facilitate early recognition of disease in a patient at high risk.

Next Article:

Left ventricular thrombosis can still complicate acute myocardial infarction

Related Articles