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Diagonal Ear Lobe Crease and Coronary Artery Disease

A recent paper published in the AJE1 regarding the relation of diagonal ear lobe crease (DELC) with coronary artery disease (CAD) raised our great interest, because it addressed an important issue linked to our previous research about dermatologic indicators of coronary risk.2 In the study by Shmilovich et al, the observation that DELC is independently and significantly associated with the increased prevalence, extent, and severity of CAD supports the results of several investigations, including our one, that have been published within last decades. However, because the prevalence of DELC increases with age, as does atherosclerotic diseases, other investigators denied this association and pointed out that age most importantly influences the appearance of DELC. Since age is one of the most important cardiovascular risk factors, and advanced age is associated with an increased incidence of DELC, baldness, hair graying and wrinkling of the skin, we set the hypothesis that the premature or extensive occurrence of these dermatological signs in males under 60 could suggest a person with an accelerated atherosclerosis. In our hospital-based case-control study, which included 842 men under the age of 60 years admitted for the first nonfatal myocardial infarction (MI) and 712 controls admitted with noncardiac diagnoses without clinical signs of CAD, we examined the association of above mentioned dermatological signs with the risk of MI. All of those signs were more common among cases compared to control, while the parietal baldness and DELC were the strongest predictors of MI. By using highly sensitive and specific imaging method in a large cohort of consecutive patients, the study by Smilovich et al.1 in vivo confirmed our hypothesis. In this consideration, other dermatological indicators of cardiovascular risk should not be ignored. Several studies have demonstrated an independent association between parietal baldness, hair graying and wrinkling of the skin with CAD. It seems that these dermatological features in CAD patients have more than esthetic meaning. Because younger persons with such features appear older than their age pairs, and perhaps these changes could be an omen of premature biological aging. Recently published data suggest that free radical oxidative stress (ROS) could be a mechanism linking dermatological signs with cardiovascular diseases. Namely, ROS – a mechanism important in atherogenesis - is enhanced in the hair follicle melanocytes and leads to their selective premature aging and apoptosis. A similar mechanism could be involved in the pathogenesis of skin damage, causing its aging, wrinkling or DELC development, by activating the metalloproteinases that break down type I collagen. ROS is one of the principal mechanisms in the shortening of telomeres, which represent ‘biological clock’ of the cell. Telomeres shortening in leukocytes may reflect cumulative burden of oxidative stress and inflammation in circulation during an individual’s lifetime. A close relationship between telomeres length in leukocytes and vascular cells confirms the leukocytes telomeres shortening as a useful marker of accelerated cardiovascular aging. In that same line, shorter leukocytes telomeres in patients with DELC than in their age matching pairs without that sign, supports appearance of DELC at an earlier age as a sign of disproportion between chronological and biological age of an individual. Finally, a positive association of DELC with carotid IMT and arterial stiffness, widely accepted markers of subclinical atherosclerosis, has also been demonstrated. Therefore, the presence of DELC may be an independent surrogate marker of atherosclerosis, even in patients with no traditional cardiovascular risk factors or clinically expressed cardiovascular diseases. A man is as old as his arteries said English physician Thomas Sydenham in the seventeenth century. Presence of some dermatological signs might indicate an advanced arterial age regardless of the number, duration or magnitude of traditional cardiovascular risk factors. That is why above mentioned potential dermatological indicators of premature biological aging should be further investigated and could be considered together with traditional factors in assessing cardiovascular risk and diagnostic approach in some patient

diagonal ear lobe crease; coronary artery disease

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