Clinical Biochemistry & Rheumatology & Family Medicine

ESR - Erythrocyte Sedimentation Rate

The erythrocyte sedimentation rate (ESR) is one of the oldest and most widely used biological tests in medicine - measuring the rate at which erythrocytes (red blood cells) sediment downwards in a tube of anticoagulated blood (sodium citrate) left upright for one hour + expressed in mm/h (Westergren method). This sedimentation phenomenon is accelerated by any increase in acute-phase plasma proteins - mainly fibrinogen + immunoglobulins + and C-reactive protein - which promote the formation of erythrocyte rolls (roll phenomenon = stacking of red blood cells, which increases their mass and accelerates their sedimentation). The VS is therefore an indirect and non-specific marker of systemic inflammation - it rises in virtually all inflammatory + infectious + autoimmune + and neoplastic conditions - without indicating the cause of this inflammation. Its main advantages are its low technical complexity + low cost + and universal availability. Its main limitations are its low specificity (many non-pathological conditions raise it: advanced age + pregnancy + female sex + anemia) + its slow kinetics (rises in 24-48 h + returns to normal in days to weeks after resolution of inflammation - unlike CRP, which rises and falls within hours) + and its insufficient sensitivity for mild or early inflammation. In modern clinical practice + the SV remains particularly useful in two specific contexts: the diagnosis and follow-up of giant cell arteritis (Horton's temporal arteritis - SV classically very high + often >100 mm/h) + and the diagnosis and follow-up of multiple myeloma (SV massively elevated by monoclonal immunoglobulins).

Normal values by age and sex

Man < 50 years old: VS normal ≤ 15 mm/h
Woman under 50: vs normal ≤ 20 mm/hr
Man > 50 years old: ES normal ≤ 20 mm/h (some use the formula age/2)
Woman > 50 years old: Normal ≤ 30 mm/h (some use the formula (age + 10)/2)
Pregnancy: VS physiologically elevated (up to 40–50 mm/h) due to increased fibrinogen and immunoglobulins
Miller's formula (simple approximation): VS maximal normal = age ÷ 2 (men) or (age + 10) ÷ 2 (women) → ex: 70-year-old man → normal VS ≤ 35 mm/h

Causes of elevation by level

VS Level	Main causes	Orientation
Slightly elevated ESR (20–40 mm/h)	Advanced age + pregnancy + obesity + mild viral infections + smoking + mild anemia + medications (oral contraceptives + dextran)	Often clinically insignificant + no extensive workup if asymptomatic + monitor
Moderately elevated VS (40–70 mm/h)	Bacterial infections + autoimmune diseases (rheumatoid arthritis + lupus + sarcoidosis + IBD) + solid cancers + moderate anemia + kidney failure + hypothyroidism	Investigation according to clinical context + CBC + CRP + infectious workup + autoimmune workup if symptomatic
Very high VS (70–100 mm/h)	Severe infections (endocarditis + abscess + osteomyelitis + tuberculosis) + active autoimmune diseases + vasculitis + polymyalgia rheumatica + advanced cancers + lymphomas	Mandatory etiological investigation + hospitalization according to the clinical presentation
Very high rainfall (>100 mm/h)	Multiple myeloma +++ (monoclonal immunoglobulins) + giant cell arteritis / Horton's disease +++ + Waldenström's macroglobulinemia + certain severe infections (miliary tuberculosis + endocarditis) + severe autoimmune diseases	Serum protein electrophoresis (myeloma) + urgent vasculitis workup if headaches + temporal pain + vision changes (temporal arteritis)

VS vs CRP — Clinical Comparison

CRP (C-reactive protein) — benefits: Fast kinetics (rise in 4–6 h + returns to normal in 24–48 h after resolution) + more specific than ESR + not influenced by anemia, pregnancy, age, or sex + better marker for monitoring response to antibiotic and anti-inflammatory treatment + marker of choice for monitoring acute infections
VS — Advantages: Useful for chronic inflammation + monitoring of polymyalgia rheumatica + temporal arteritis + myeloma + sarcoidosis + tuberculosis → ESR can remain elevated for weeks to months after inflammation resolution (long-term integration) → useful for detecting insidious chronic disease
Additional use: High ESR + normal CRP → suspicion of myeloma (immunoglobulins speed up ESR without activating hepatic CRP synthesis in the same way) + normal ESR + high CRP → recent acute inflammation (ESR hasn't had time to rise yet) + both ESR and CRP high → documented active inflammation
High monoclonal protein VS normal CRP → myeloma until proven otherwise: Monoclonal immunoglobulins massively accelerate red blood cell rouleaux formation (very high ESR) + without necessarily raising CRP to the same level → urgent serum protein electrophoresis

Causes of falsely low ESR (low ESR despite inflammation)

Polyglobulin : excess red blood cells → compaction → slowed sedimentation
Sickle cell disease: sickle cells do not form rouleaux → very low VS even in case of infection or vaso-occlusive crisis
Congestive heart failure hemodilution + low albumin + reduced sedimentation factors
Hypofibrinogenemia congenital or acquired deficit (DIC) → reduced sedimentation
Corticosteroid + NSAID treatment acute phase protein reduction → decreased ESR despite underlying active inflammation

ℙ️ A very high ESR (>100 mm/h) with moderately elevated or normal CRP should systematically suggest multiple myeloma – monoclonal immunoglobulins (IgG + IgA + IgM) massively accelerate the formation of red blood cell rouleaux and the sedimentation rate, without necessarily triggering a proportional CRP response. Serum protein electrophoresis + immunoglobulin assay + urinary Bence-Jones protein detection should be performed for any ESR > 100 mm/h without an obvious inflammatory or infectious cause.

Medical consultation recommended

Consult a doctor quickly if a very high ESR (>70–100 mm/h) is discovered—particularly if accompanied by temporal headaches + jaw pain + visual disturbances (temporal arteritis—ophthalmological emergency) + or bone pain + fatigue + anemia (multiple myeloma). Temporal arteritis with a very high ESR and risk of blindness requires emergency corticosteroids EVEN BEFORE a temporal artery biopsy. For the clinical interpretation of an elevated ESR and etiological work-up, Clinique Omicron offers medical consultations at its service points in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.

Consult at Clinique Omicron

Clinique Omicron's physicians and Nurse Practitioners (NPs) interpret the ESR in the appropriate clinical context (always with CRP + CBC + infectious or autoimmune workup depending on symptoms), suspect myeloma in cases of very high ESR with moderate CRP (serum protein electrophoresis), recognize the urgency of temporal arteritis (high ESR + headaches + visual disturbances → immediate corticosteroids), and monitor chronic inflammatory diseases (polymyalgia + temporal arteritis + RA + sarcoidosis) using combined ESR and CRP. Consultations are available at multiple service points in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.

The content of this page is for informational purposes only and does not substitute professional medical advice. ESR should never be interpreted in isolation—it must always be considered in conjunction with CRP and the clinical context. Temporal arteritis (Horton's disease) with a very high ESR, headaches, and visual disturbances constitutes a medical emergency—corticosteroids must be initiated immediately without waiting for a biopsy to prevent irreversible blindness.

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