Earlobe Crease Shapes and Cardiovascular Events Claudia Rodríguez-López, MDa, Hugo Garlito-Díaz, MDa, Raquel Madroñero-Mariscal, MDa, Pablo Jesús Sánchez-Cervilla, MDa, Auxiliadora Graciani, MD, PhDa, José Luis López-Sendón, MD, PhDb, and Esteban López-de-Sá, MDb,* Earlobe crease (ELC) has been linked to coronary artery disease; however, systematic evaluations of the earlobe and its relation to ischemic stroke are lacking. The objectives were to define the ELC using a single-blind approach and to determine through multivariate analysis its association with cardiovascular events (CVEs) comprising coronary, ischemic cerebrovascular, and peripheral vascular diseases. A single-blind cross-sectional study was performed in 2 phases: (1) an initial study (n [ 300) to define ELC classification criteria and (2) a confirmation stage (n [ 1,000) to analyze ELC association with CVEs. Each of the participants’ pinnae were photographed and classified blindly by joint decision according to ELC’s inclination, length, depth, and bilateralism. Patients’ medical histories were reviewed for age, cardiovascular risk factors, and CVEs. The concordance rate after the classification of all photographs was 89.6%. The first phase did not find any correlation between the different depth degrees or vertical creases and CVEs. The second stage concluded that diagonal bilateral ELC prevalence in patients with CVEs was 43% compared with 29% in the control patients (p 18 years admitted to the medical wards of the Hospital Universitario La Paz, Madrid, Spain, from March 15, 2014, to June 15, 2014, were eligible to participate in this cross-sectional study. The protocol and consent procedure were approved by the institutional ethics committee in accordance with the European guidelines for good clinical practice and with the ethical guidelines of the 1975 Declaration of Helsinki. The patients were informed about the study, and written consent was obtained before inclusion. The study was divided into 2 phases: (1) the first phase enrolled 300 patients to typify the various ELC features, determining the sensitivity, specificity, and predictive values of each characteristic in detecting atherosclerosis; (2) the second phase enrolled 700 additional patients, bringing the total sample to 1,000 patients, using the classification criteria previously determined for the first phase. After signing the informed consent, the patients had both pinnae photographed by a researcher who assigned to each participant an identification number attached to their photographs, which remained linked to their medical record number in a protected database to ensure data confidentiality. To preserve the blinding, a different researcher reviewed the medical record of each patient for their birth date, gender, coronary risk factors, history of myocardial www.ajconline.org

Miscellaneous/Earlobe Crease Shapes and Cardiovascular Events

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Figure 1. Classification of the ELC according to length. (A) Complete and (B) incomplete.

Figure 2. Classification of the ELC according to depth. (A) Mild (vaguely insinuated); (B) moderate (a fold where the base of the sulcus can be observed); and (C) severe (base of the sulcus cannot be seen).

infarction, coronary revascularization, stroke, transient ischemic attack (TIA), atrial fibrillation, carotid stenosis, aortic aneurysm, aortic dissection, lower limb vascular disease, cancer, and laboratory data.

Finally, all pinnae were classified by consensus among 3 researchers. Discrepancies were solved by consensus with the participation of a fourth researcher. Each photograph was classified according to the following characteristics:

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Figure 3. Classification of the ELC according to its course. (A) Diagonal crease extending between the tragus and the posteroinferior lobe edge. (B) Vertical crease extending between the tragus and the anteroinferior lobe edge. (C) Unclassifiable earlobe: When the presence of the ELC could not be determined, all were considered negative (in this case, the lobe was cut off despite the insinuation of a diagonal crease).

length, depth, bilateralism, and inclination. Length (Figure 1) was qualified as complete when the line crossed the entire distance from the tragus to the earlobe’s edge (Figure 1) and incomplete when it crossed >1/3 of the earlobe without reaching the border (Figure 1). Depth (Figure 2) was qualified as mild when it faintly insinuated (Figure 2), moderate when it marked a fold where the end could be appreciated (Figure 2), and severe when the end of the fold could not be seen (Figure 2). The ELC was considered bilateral when any line appeared in both ears and unilateral if it only appeared in 1. Finally, 2 creases referring to the inclination were defined (Figure 3): a diagonal crease that extended from the tragus posterolaterally or inferiorly to the lobe (Figure 3) and a vertical crease that ended anteromedially to this site after running close and parallel to the lobe medial edge (Figure 3). Earlobes where the presence of the crease could not be determined were considered as ELC negative (Figure 3). The continuous variables are presented as mean  SD and were compared using Student’s t test; the categorical variables were compared using the chi-square test or Fisher’s exact test. The concordance rate after the photograph classification was estimated from the number of photographs about which any of the 3 investigators disagreed. The Cochrane-Armitage trend test was applied for analysis between different ELC types and CVEs. Sensitivity, specificity, and predictive values were calculated from the contingency tables of ELC-CVEs. The effect was quantified by univariate and multivariate logistic regression models. All the variables were modeled categorically using

dummy variables. Statistical significance was set at p