Sedimentation rate (VS)
Normal values by age and sex
- Miller formula (rapid estimation of upper normal limits) : man = age / 2 + woman = (age + 10) / 2 → examples: man 50 → VS < 25 mm/h + 50-year-old woman → VS < 30 mm/h + 70-year-old man → VS < 35 mm/h + 70-year-old woman → VS < 40 mm/h
- Normal reference values : man < 50 years : < 15 mm/h + homme > 50 years : < 20 mm/h + female < 50 years : < 20 mm/h + femme > 50 years : < 30 mm/h + child : < 10-15 mm/h
- Slightly high SV (20-50 mm/h): variable clinical significance + can be physiological in the elderly + pregnant women + or pathological in many mild to moderate conditions
- Moderately high SV (50-100 mm/h): significant + suggests active infection + chronic inflammatory disease + neoplasia
- Very high SV (> 100 mm/h): clinically very important threshold value → 90 % of cases have an identifiable serious cause → systematic in-depth workup → giant cell arteritis (GCA) ++ + multiple myeloma ++ + severe infections + severe autoimmune diseases + lymphomas
Causes of elevated SV
| Category | Main causes | Mechanism and context |
|---|---|---|
| Inflammatory rheumatological diseases | Giant cell arteritis (GCA - temporal arteritis) ++ + polymyalgia rheumatica (PMR) ++ + rheumatoid arthritis + lupus + axial spondyloarthritis + vasculitides + connectivites | ACG and PMR: SV often > 50-100 mm/h + SV = major diagnostic criterion for ACG + also monitoring criterion for corticosteroid treatment (normalization expected under treatment) |
| Acute and chronic infections | Severe bacterial infections + infective endocarditis + osteomyelitis + tuberculosis + deep abscesses + chronic HIV + HCV + HBV infections | Fibrinogen increases in 24-48 h during infection → high SV + less sensitive than CRP for acute infections + but useful for chronic infections (tuberculosis + endocarditis) |
| Hematological malignancies | Multiple myeloma +++ (very high levels of monoclonal immunoglobulins) + Waldenström macroglobulinemia + lymphomas | Myeloma: classic cause of very high VS (> 100 mm/h) due to accumulation of monoclonal immunoglobulins → systematic serum protein electrophoresis if unexplained VS > 100 mm/h |
| Solid cancers | Kidney cancer + lung cancer + colorectal cancer + gastric cancer + metastases + paraneoplastic | Moderate to severe elevation + mechanism: acute phase proteins + necrosis + inflammation + must be evoked if VS elevated with no other obvious explanation + especially after age 50 |
| Physiological (non-pathological) causes | Pregnancy (2nd-3rd trimester) + menstruation + advanced age + obesity | Pregnancy: VS may reach 40-70 mm/h normally (fibrinogen increases physiologically) + old age: VS tends to increase with age even without pathology → use Miller's formula to adjust normals |
| Anemia | Any cause of anemia → VS increased by physical mechanism | Fewer erythrocytes → less repulsion → faster sedimentation → correction: the SV must be interpreted taking into account the hematocrit (low hematocrit = artificially high SV) |
| Chronic renal failure | CKD → accumulation of inflammatory proteins + anemia + hypoalbuminemia | VS often moderately elevated in CKD → less specific for diagnosis of additional inflammation |
Causes of low or normal SV despite inflammation - false negatives
- Polyglobulin : very high hematocrit → RBCs are too numerous → repulsion between RBCs dominates → slowed sedimentation → falsely normal or low ESR even if inflammation is real
- Cryoglobulinemia + hypofibrinogenemia + DIC : abnormal or reduced proteins → lowered VS
- Sickle cell disease: Sickle RBCs do not stack in rolls → very low SV
- Severe congestive heart failure : hypervolemia → protein dilution → lowered VS
- Active lupus : paradoxically, relapsing lupus may have a normal or low SV (immune complexes + cryoglobulins + fibrinogen consumption in associated DIC) → CRP is a better marker of lupus activity
SV in giant cell arteritis (GCA) - crucial clinical use
- Typical presentation : woman > 50 (peak 70-80) + temporal headaches + painful, indurated temporal artery + jaw claudication + visual disturbances (fleeting amaurosis → permanent blindness if untreated) + associated polymyalgia rheumatica in 50 % of cases
- VS in ACG : VS > 50 mm/h is a major ACR criterion for CTA + VS > 100 mm/h is highly suggestive + but 5-10 % of CTAs have a normal VS → do not exclude the diagnosis on a normal VS if there is strong clinical suspicion → temporal artery biopsy + echo-Doppler of temporal arteries + PET-CT
- Urgent treatment (do not wait for biopsy): prednisone 60 mg/day per os as soon as clinical suspicion arises → prevention of irreversible blindness → biopsy remains positive for 2-4 weeks on corticosteroids
- Treatment follow-up : VS and CRP normalize on corticosteroids in 2-4 weeks → monthly monitoring to guide the decrease + a further rise suggests a relapse
Consult a physician within 24 hours if a very high SV (> 100 mm/h) is detected with no obvious cause - this result warrants a thorough workup (protein electrophoresis + CBC + CRP + renal + liver workup + imaging depending on the context). Immediate emergency consultation if elevated SV is accompanied by temporal headache + visual disturbances + jaw claudication in a person over 50 - this picture suggests giant cell arteritis, an ophthalmological emergency requiring urgent corticosteroids to prevent blindness. For prescription and interpretation of SV, Clinique Omicron offers consultations at its points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's specialized physicians and nurse practitioners (NPs) prescribe and interpret the SV in its clinical context, combining it with CRP, CBC and other inflammatory markers, distinguishing physiological from pathological causes of elevation, prescribe the appropriate investigative work-up according to the SV level and associated clinical signs, initiate corticosteroids as a matter of urgency if giant cell arteritis is suspected, and refer to rheumatology + hematology or oncology depending on the etiology identified. Consultations are available at several points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The contents of this page are provided for information purposes only and do not replace medical advice. The sedimentation rate is a non-specific test that should always be interpreted in the full clinical context and in conjunction with CRP and other laboratory tests. A normal VS does not exclude a serious inflammatory disease - notably giant cell arteritis in 5 to 10 % of cases.
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