Frank's sign: Can an 'innocent' wrinkle on the earlobe predict a heart attack?

Every year, 17.9 million people die from cardiovascular disease (CVD), which includes heart and cerebrovascular diseases. Today, CVD is the leading cause of death worldwide , and the number is estimated to rise to 23 million by 2030.

These figures consolidate cardiovascular disease's ranking as the leading cause of death , occupying the top positions both worldwide and in Spain. A position it remains in year after year despite ongoing health campaigns to raise awareness and save lives.

One of the factors that makes diagnosis and treatment of some cardiovascular diseases difficult is their asymptomatic nature. An example of this is high blood pressure , one of those conditions that can persist for years without showing its face, while gradually damaging the health of those who suffer from it.

Therefore, the possibility of having a warning sign for cardiovascular disease is especially interesting. One of these is known as Frank's sign, "a diagonal fold or groove in the earlobe that extends from the tragus (the small cartilaginous prominence in front of the ear canal) toward the outer edge of the lobe, at an angle of approximately 45 degrees," describes Dr. Luis Rodríguez Padial, president of the Spanish Society of Cardiology (SEC) .

The lobe and cardiovascular risk

Frank's sign was first described in 1973 by American pulmonologist Saunders T. Frank in a letter published in The New England Journal of Medicine . He observed that 19 of 20 patients with this fold had at least one known cardiovascular risk factor, leading him to propose its association with coronary artery disease.

“This sign is considered a 'cutaneous marker' that could reflect underlying processes related to vascular aging or endothelial dysfunction,” the doctor points out, emphasizing that “although it has been described as a possible marker of ischemic heart disease or atherosclerosis, its usefulness remains a matter of debate .”

In one ear or both?

Beyond the (more or less close) relationship between that small cleft in the ear and cardiovascular health, let's look at how to recognize it. According to the expert, "it's identified as a diagonal crease in the earlobe: it begins at the inner edge of the external auditory canal and runs toward the outer edge of the lobe. It can be complete (crossing the entire lobe) or incomplete, and its depth can vary."

Furthermore, "it can appear in one or both ears, with bilateral ear cancer being associated with a higher cardiovascular risk . It can be detected through a simple visual inspection," the doctor emphasizes.

The problem is that "it can be confused with common wrinkles associated with aging, since the earlobe tends to develop creases with age. However," the doctor continues, "it is not simply an aging wrinkle, as it has specific characteristics. To differentiate it, it is key to evaluate its specific shape and consider the patient's clinical context , such as the presence of other cardiovascular risk factors."

Indicates, but does not determine

It's important to consider that having this wrinkle doesn't necessarily mean that a person is at greater cardiovascular risk than someone who doesn't have it. "We can't say it's a definitive warning sign, but it can be an indicator of cardiovascular risk, especially in people with other risk factors (hypertension, diabetes , smoking, obesity, dyslipidemia) or in younger individuals," says Rodríguez Padial.

Not everyone with Frank's Sign has a higher risk of cardiovascular disease.

Furthermore, if it appears, it's best to " consult a doctor to evaluate your risk factors and personal history. The professional will determine if specific tests are necessary. It's also important to maintain a healthy lifestyle to reduce cardiovascular risk," the expert advises.

Furthermore, he insists that "not all people with Frank's sign are at increased risk for cardiovascular disease. The presence of the sign must be interpreted in the context of other factors: bilaterality and depth, the patient's age, risk factors, and ethnicity. In other words, the sign is a marker that, when combined with other factors, may warrant further evaluation."

Scientific studies and conclusions

As for the scientific explanation behind the link between Frank's Sign and cardiovascular risk, specifically its association with atherosclerosis, risk factors and cardiovascular events, the truth is that, according to the doctor, " the exact mechanism is not fully understood ."

However, there are some studies that have investigated this association , and their results vary in terms of the strength of the relationship. Of all of them, the doctor highlights the following:

• 1973 study (Frank, NEJM): Saunders T. Frank initially described the association in a letter to the New England Journal of Medicine , noting that 19 of 20 patients with the sign had cardiovascular risk factors.
• A Estrada Study (2019): An epidemiological study of 1,050 people found that Frank's sign is more prevalent in patients with hypertension, diabetes, hypercholesterolemia, and obesity, and is associated with cardiovascular risk indices such as Framingham, REGICOR, SCORE, and ASCVD. It also showed histomorphological changes, such as lower capillary density in the lobe.
• A study conducted with 300 participants and presented at the 2014 SEC Congress found that 48.9% of patients with a history of stroke and 45.8% with a heart attack had the sign, compared to 27.8% and 28.2% of those without such a history.

On the other hand, much of the research conducted suggests that age could be a confounding factor, "since the symptom is more common in older people, where cardiovascular risk is also higher. Specifically, according to the available scientific evidence, it is rare in people under 30, becoming more common after age 50," the doctor adds.