A diagonal crease running across the earlobe has been linked to coronary artery disease in dozens of studies since the 1970s, but its diagnostic accuracy is not good enough to tell you whether you actually have heart disease. A 2021 systematic review pooling data from 13 studies and nearly 4,000 patients concluded that the crease “only slightly changes pre-test probability” and should not, on its own, affect clinical decisions. The association is real in a statistical sense, yet the story behind it involves aging, connective tissue, and confounding variables that make the crease far less useful than it sounds.
What the Earlobe Crease Actually Is
The crease in question is a diagonal line or wrinkle that runs roughly 45 degrees from the small flap of cartilage at the front of the ear canal (the tragus) backward toward the outer rim of the ear. It was first formally described in 1973 by an American physician named Sanders T. Frank, who noticed it in a group of patients with chest pain and went on to associate it with coronary artery disease. The crease has been called “Frank’s sign” ever since, and it appears in medical literature under the abbreviation DELC (diagonal earlobe crease) or simply ELC.
Not every wrinkle on the ear qualifies. The classic sign is a distinct, unbroken diagonal fold that cuts across most or all of the lobe. Shallow creases, short creases near the edge, and wrinkles that run vertically are generally not considered the same thing, though grading systems vary between studies, which is part of why the research has been hard to pin down.
What the Studies Actually Show
The association between the earlobe crease and coronary artery disease has been studied for over fifty years, and the overall picture is mixed. A systematic review that analyzed 13 cross-sectional studies found sensitivity ranging from 26% to 90% and specificity ranging from 32% to 96%. Those ranges are enormous, which is itself a red flag for a diagnostic marker. Most of the positive likelihood ratios fell below 2, meaning the crease barely shifts the probability that someone has coronary disease. The review’s authors were blunt: diagnostic accuracy is “insufficient.”1PubMed Central. Diagonal Earlobe Crease (Frank’s Sign) for Diagnosis of Coronary Artery Disease: A Systematic Review of Diagnostic Test Accuracy Studies
A 2025 forensic pathology study took a different approach, examining the earlobes of deceased individuals and comparing them to autopsy findings of fatal coronary artery disease. This study found high specificity (about 86%) and a reasonable negative predictive value (about 85%), meaning that if you do not have the crease, there is a decent chance you do not have severe coronary disease. But sensitivity was only about 61%, and the overall discriminative power was rated “fair.”2PubMed. Ear-ly Warnings: The diagnostic accuracy of Frank’s sign in fatal coronary artery disease – A forensic pathology study In practical terms, roughly four out of ten people who die from coronary artery disease do not have the crease, so its absence is not reassuring enough to stand alone.
A Chinese study of patients undergoing angiography found that the crease remained a positive predictor of coronary artery disease even after adjusting for age, sex, and traditional risk factors, with odds roughly three and a half times higher in people with the crease compared to those without. But even in that study, the crease was not useful for predicting other conditions like high blood pressure, diabetes, or elevated cholesterol.3PubMed Central. Diagonal earlobe crease and coronary artery disease in a Chinese population
The Age Problem
The single biggest complication in all of this research is age. The earlobe crease becomes more common as people get older, and so does heart disease. Separating the two has been a persistent headache for researchers. A population-based study looking at carotid artery thickness, a standard marker of atherosclerosis, initially found a significant association with the earlobe crease. But once age was added to the statistical model, the association vanished. The authors concluded that the thickening of artery walls seen in people with earlobe creases was better explained by aging itself.4PubMed Central. On the association between earlobe crease and the carotid intima-media thickness: A population-based study
A study of Mexican adults drilled further into the demographics. It found that aging, obesity, high blood pressure, and being male were the factors most strongly associated with having an earlobe crease. The researchers noted that finding the crease during a physical exam “may be indicative of cardiovascular risk” but “may also simply be due to aging, especially in men.” Their hypothesis was that the crease reflects changes in skin and connective tissue produced by aging and body composition, which also happen to be risk factors for cardiovascular disease through their own well-known pathways.5PubMed Central. Traditional Cardiovascular Risk Factors Associated with Diagonal Earlobe Crease (Frank Sign) in Mexican Adults: Aging, Obesity, Arterial Hypertension, and Being Male Are the Most Important
Ethnicity also clouds the picture. Some studies have found no significant relationship between the crease and coronary disease in American Indian and Japanese-American populations. The reported frequency of the crease varies widely across ethnic groups, and nobody is entirely sure what to make of that.6PubMed Central. The Diagonal Earlobe Crease: Historical Trivia or a Useful Sign of Coronary Artery Disease?
One Ear or Both Ears
Whether the crease appears on one earlobe or both seems to matter. Research consistently suggests that bilateral creases carry more weight than a crease on just one side. A study that compared cardiovascular risk scores across groups found that the estimated risk of cardiovascular death roughly doubled or tripled going from no crease to bilateral creases, depending on which scoring system was used. People with bilateral creases had a mean Framingham risk score of about 14%, putting them in the moderate-risk category, compared to about 5.4% for those without a crease.7The American Journal of Medicine. Relationship between Diagonal Earlobe Crease and Cardiovascular Risk Indices
Cohort studies have similarly reported that people with bilateral creases tend to have worse prognoses for coronary artery disease than those with unilateral creases, who in turn do worse than those with no creases.8PubMed Central. Bilateral Earlobe Crease as a Marker of Premature Coronary Artery Disease If you are going to pay any attention to the crease at all, the bilateral version is the one that shows up more reliably in the data.
What Is Happening Under the Skin
One of the more interesting questions is whether the crease shares a biological mechanism with cardiovascular disease or is simply a coincidental byproduct of aging. Histological studies, where researchers examine earlobe tissue under a microscope, have found some suggestive changes. One study found that the connective tissue architecture in creased earlobes is reorganized: collagen fibers dominate over elastic fibers, and instead of the normal pattern of small tissue partitions surrounding fat, the crease contains a large connective tissue band with fat on either side.9European Journal of Dermatology. The diagonal earlobe crease: a histological and capillaroscopic analysis
Another histological study found thickening and scarring in a small artery at the base of the crease, along with degeneration of peripheral nerves and widespread fibrosis in the deeper tissue. The researchers reported that these changes correlated with changes in heart muscle tissue, suggesting the crease and heart disease might share a common process involving small-vessel damage and connective tissue breakdown.10PubMed Central. The Histological Basis of Frank’s Sign This is the strongest evidence for a shared biological pathway rather than pure coincidence, though the sample sizes in histological studies tend to be small.
Not everyone buys the vascular explanation. An alternative theory holds that the crease is mechanical: the earlobe gets compressed between the skull and a pillow or mattress during sleep, or that heavier cheeks pull on the lobe and create a fold over time.11PubMed Central. Paired Ear Creases of the Helix (PECH): A Possible Physical Sign This theory is hard to test rigorously, but it offers a plausible non-cardiac explanation for why the crease becomes more common with age and higher body weight.
Connections Beyond the Heart
The crease has been linked to more than just coronary artery disease. Some studies have found associations with carotid artery thickening, a sign of atherosclerosis in the blood vessels supplying the brain. One study of people without any clinical cardiovascular symptoms found that those with the earlobe crease had significantly thicker carotid artery walls, and the association held even after adjusting for other variables.12PubMed. Diagonal ear-lobe crease is associated with carotid intima-media thickness in subjects free of clinical cardiovascular disease Reports have also linked the crease to calcified plaques visible on dental X-rays, which is an odd but documented way that atherosclerosis sometimes shows up.13PubMed Central. Diagonal ear lobe crease and atherosclerosis: a review of the medical literature and dental implications
A study of Chinese stroke patients found that those with earlobe creases were more likely to have certain markers of small-vessel disease on brain imaging, including a particular type of white-matter change near the brain’s ventricles and, strikingly, brain atrophy. Bilateral creases were associated with even higher odds of these findings.14PubMed. Associations between Earlobe Creases and Magnetic Resonance Imaging Small Vessel Disease Markers in a Chinese Cohort of Patients with Ischemic Stroke Whether the crease predicts stroke itself remains unclear. A smaller study that specifically tried to answer that question could not draw conclusions because too few patients in their sample had the crease.15Open Access Macedonian Journal of Medical Sciences. Relationship between Diagonal Earlobes Crease and Ischemic Stroke Risk
Metabolic syndrome, the cluster of conditions including central obesity, elevated blood sugar, high blood pressure, and abnormal cholesterol, has also shown an association with the crease. A cross-sectional study in Korean adults found that the odds of metabolic syndrome were higher in people with the crease, even after adjusting for conventional cardiovascular risk factors, though the researchers acknowledged the prognostic value was limited.16PubMed Central. Association Between Earlobe Crease and the Metabolic Syndrome in a Cross-sectional Study
Does the Crease Predict Who Dies After a Heart Attack
One area where the crease has shown some prognostic punch is in people who have already had a heart attack. A study that followed heart attack survivors found that patients with deeper creases (graded 2 or 3 on a 0-to-3 scale) had a nearly twofold higher risk of death over the next three years in unadjusted analysis. After accounting for other factors, the association weakened, but a subgroup analysis of patients under 65 still showed a roughly two-and-a-half-fold higher risk of death for those with deep creases.17PubMed Central. Diagonal earlobe crease and long-term survival after myocardial infarction
A more recent study, presented at a European cardiology meeting, used CT angiography to examine the creases alongside coronary plaque characteristics. Patients with the crease were more likely to have high-risk plaques and experienced worse long-term outcomes, including higher all-cause mortality and more repeat procedures. Both the crease and high-risk plaques independently predicted worse outcomes.18European Heart Journal. Diagonal earlobe crease as a predictor of high-risk coronary plaques and long-term cardiovascular outcomes: The DEAR study These results hint that among people already known to have heart disease, the depth and presence of the crease might add something to risk assessment. Among healthy people walking into a doctor’s office, the picture is less clear.
Should You Worry If You Have One
If you have noticed a diagonal crease on your earlobe and are wondering whether to panic, the short answer is: do not panic, but do not ignore your cardiovascular health either. The crease is not a diagnosis. It is not even a very good screening tool. Its sensitivity is inconsistent, its specificity varies wildly across populations, and the overlap with plain old aging makes it hard to interpret in any individual case. No major cardiology guideline recommends using the earlobe crease as a standalone indicator for ordering tests or starting treatment.
That said, if you happen to have the crease, particularly bilateral deep creases, and you also have other risk factors for heart disease, such as high blood pressure, smoking, diabetes, a family history of early heart attacks, or elevated cholesterol, it might be worth mentioning to your doctor. Not because the crease changes what they would do, but because it could prompt a conversation about whether your standard risk factors have been adequately evaluated. The crease sits in an odd category: too weak to act on by itself, too persistent in the literature to dismiss entirely.
What Sleep and Earrings Have to Do with It
Before spending too much time in front of a mirror, it is worth knowing that not every earlobe crease is Frank’s sign. Heavy earrings worn for years can stretch and crease the lobe in ways that mimic the diagonal fold. Side-sleepers may develop creases from chronic compression against a pillow, as one research group hypothesized. And people with larger or fleshier earlobes seem more prone to developing creases over time, independent of any cardiovascular condition.11PubMed Central. Paired Ear Creases of the Helix (PECH): A Possible Physical Sign
These mechanical and body-composition factors are rarely controlled for in the cardiac studies, which tend to focus on adjusting for smoking, blood pressure, and cholesterol rather than earring habits or sleeping posture. That gap in the research makes it harder to know how much of the observed association between the crease and heart disease is genuinely vascular and how much is noise from everyday wear and tear on the ear.
The Crease in Younger People
Most of the concern about age as a confounder applies to middle-aged and older adults, where both creases and heart disease are common. But the crease occasionally appears in younger people, and when it does, the data is more provocative. The Chinese angiography study found the lowest sensitivity but the highest positive predictive value in patients under 45. That means the crease is uncommon in younger people, but when it shows up, it is more likely to be accompanied by actual coronary disease.3PubMed Central. Diagonal earlobe crease and coronary artery disease in a Chinese population The post-heart-attack survival study also found the strongest prognostic signal in the under-65 subgroup.17PubMed Central. Diagonal earlobe crease and long-term survival after myocardial infarction
This makes intuitive sense. In a 75-year-old, an earlobe crease could mean many things. In a 40-year-old with no obvious risk factors, a clear diagonal crease is at least unusual enough to raise an eyebrow. It is not evidence of disease, but it sits in that gray zone where a clinician who notices it might think a bit harder about whether standard screening has been done. Researchers have speculated that in younger patients, the crease may reflect premature vascular aging or genetic predisposition, though concrete genetic data linking the crease to specific cardiovascular risk genes remains sparse.