Background: The diagonal ear-lobe crease (ELC) is reported to be a marker of cardiovascular disease. Very few reports have assessed the relationship of ELC with atherosclerosis. This relationship is investigated here using a Japanese population. Methods and Results: A prospective cross-sectional study included 212 consecutive patients. Bilateral ear lobes were checked for the ELC and this was followed by carotid ultrasonography to measure the far wall common carotid artery intima-media thickness (CCA-IMT), plaque score (PS) and plaque number (PN). Patients with ELC had significantly higher carotid IMT than controls (0.90 ±0.24 vs 0.77 ±0.15, respectively, P<0.001). ELC presence correlated significantly with carotid IMT, PS, and PN (r=0.306, P<0.0001; r=0.198, P<0.008 and r=0.221, P<0.0001, respectively), and also with age, male sex and hypertension. ELC presence and absence in mild or no PS and moderate or severe PS subgroups was significant, with a chi-squared value of 7.59 (P<0.006). In multivariate regression analysis, ELC presence correlated with CCA-IMT independently. The odds ratio for the presence of ELC in patients with CCA-IMT of <0.8 mm vs patients with CCA-IMT of ≥0.8 mm (the median value) was 0.41 (95% confidence interval, 0.22-0.76). Conclusions: The present study showed an association between ELC and increased CCA-IMT, PS, and PN. (Circ J 2009; 73: 1945-1949)