What is the significance of the diagonal ear lobe crease or “Frank’s sign”?

Frank’s sign, also known as diagonal earlobe crease (DELC), has often been considered a sign of coronary artery disease (CAD), originally described in patients 60 years of age or younger in 1973 (1). Since then, the majority of clinical, angiographic, and postmortem reports seem to support the association of this physical finding (see figure) with atherosclerotic coronary disease (2,3). In addition, it may be associated with peripheral vascular disease (4) as well as cerebrovascular disease (5).

In a study of hospitalized patients, there was a significant association between DELC and cardiovascular events with a sensitivity of 43% and specificity of 70% (3).

Although the mechanism for this association is unclear, microvascular disease involving the middle ear lobe end-artery territory has been implicated (6).  Free radical oxidative stress activation of the metalloproteinases that break down type 1 collagen has also been suggested (7).

It is fair to conclude, however, that the value of this sign as a screening tool for CAD has not been firmly established and its utility in clinical practice remains uncertain, particularly in those older than 60 years of age or those with diabetes (6).



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1. Frank ST. Aural sign of coronary-artery disease. N Engl J Med 1973;289:327-8. https://www.ncbi.nlm.nih.gov/pubmed/4718047

2. Friedlander AH, Lopez-Lopez J, Velasco-Ortega E. Diagonal ear lobe crease and atherosclerosis: a review of the medical literature and dental implications. Med Oral Patol Oral Cir Bucal 2012;1:e153-9. http://www.medicinaoral.com/pubmed/medoralv17_i1_p153.pdf 

3. Rodriguez-Lopez C. Garlito-Diaz H, Madronero-Mariscal R, et al. Earlobe crease shapes and cardiovascular events. Am J Cardiol 2015;116:286-93. https://www.sciencedirect.com/science/article/abs/pii/S0002914915011200?via%3Dihub

4. Korkmaz L, Agac MT, Acar Z, et al. Earlobe crease may provide predictive information on asymptomatic peripheral arterial disease in patients clinically ree of atherosclertotic vascular disase. Angiology  2014;65:303-7. https://reference.medscape.com/medline/abstract/23449604

5. Celik S, Erdogan T, Gedikli O, et al. Earlobe crease is associated with carotid intima-media thickness in subjects free of clinical cardiovascular disease. Atherosclerosis 2007;192:428-31. https://www.sciencedirect.com/science/article/abs/pii/S0021915006005284

6. Shoenfeld Y, Mor R, Weinberger A, et al. Diagonal earl lobe crease and coronary risk factors. J Am Geriatr Soc 1980;28:184-7. https://www.ncbi.nlm.nih.gov/pubmed/7365179/

7.  Fabijanic D, Culic V. Diagonal ear lobe crease and coronary artery disease. Am J Cardiol 2012;110:1385-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4697048/ 

Contributed in part by Kathryn Dinh, Medical Student, Harvard Medical School, Boston, MA.

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you


What is the significance of the diagonal ear lobe crease or “Frank’s sign”?