What is considered an elevated Erythrocyte Sedimentation Rate (ESR)?

What is Considered an Elevated ESR?

An elevated erythrocyte sedimentation rate (ESR) is generally defined as >20 mm/h in men and >30 mm/h in women, though specific thresholds vary by clinical context and higher values indicate greater likelihood of underlying disease. 1

Normal and Elevated ESR Values

• ESR values are typically considered elevated when they exceed the following thresholds:

  • Men: >20 mm/h 1
  • Women: >30 mm/h 1
  • Elderly persons: Values up to 35-40 mm/h may be normal due to age-related changes 2

• The degree of elevation correlates with clinical significance:

  • Mild elevation (20-50 mm/h): May be seen in mild inflammation or age-related changes 3
  • Moderate elevation (50-100 mm/h): More likely to indicate significant underlying disease 1
  • Marked elevation (>100 mm/h): Has a 90% predictive value for serious underlying disease, most commonly infection, collagen vascular disease, or metastatic malignancy 4

Clinical Interpretation of ESR Values

• ESR lacks specificity and sensitivity as a standalone test but provides valuable information when interpreted in clinical context 4

• In giant cell arteritis (GCA), specific ESR thresholds have diagnostic significance:

  • ESR >40 mm/h: High sensitivity (93.2%) for GCA with negative likelihood ratio of 0.18 1
  • ESR >50 mm/h: Sensitivity of 78.9% for GCA 1
  • ESR >60 mm/h: Better specificity (70.5%) with positive likelihood ratio of 2.40 1
  • ESR >100 mm/h: Highest specificity (92.2%) with positive likelihood ratio of 3.11 1

• In Kawasaki disease, ESR is often above 40 mm/h and commonly reaches levels of at least 100 mm/h 1

• In diabetes-related foot infections, a highly elevated ESR (≥70 mm/h) has a sensitivity and specificity of 81% and 80%, respectively, for diagnosing osteomyelitis 1

Factors Affecting ESR Values

• Age: ESR increases with age, but elevated values remain prognostically significant even in elderly patients 2, 3

• Gender: Women typically have higher baseline ESR values than men 1

• Comorbidities: Anemia and azotemia can artificially elevate ESR values 1

• Timing: ESR responds more slowly to acute inflammation than other markers like CRP, making it less useful for detecting acute changes 1

• Measurement method: Values may differ between automated methods and the standard Westergren method, particularly at higher ESR levels 5

Clinical Applications and Limitations

• ESR should not be used as a screening test in asymptomatic individuals 4

• An ESR value exceeding 100 mm/h warrants thorough investigation due to high association with serious disease 4

• ESR is particularly useful in monitoring conditions such as:

  • Giant cell arteritis and polymyalgia rheumatica 1
  • Kawasaki disease (though CRP may be more accurate after IVIG therapy) 1
  • Hodgkin's lymphoma monitoring 1

• False-negative results (normal ESR despite disease) occur in approximately 25% of elderly patients with both malignant and non-malignant diseases 2

• When an unexplained elevated ESR is found without obvious cause, repeating the test in several months is more appropriate than pursuing extensive diagnostic testing 4