Normal ESR Values
Normal ESR values vary by age and sex, with upper limits generally around 20 mm/h for men and 30 mm/h for women, though these thresholds increase with age. 1
Standard Reference Ranges
The American College of Physicians defines elevated ESR as values exceeding 20 mm/h in men and 30 mm/h in women. 1
For elderly patients, ESR may be as high as 35-40 mm/h in healthy individuals without indicating disease. 2
Women consistently have higher baseline ESR values than men across all age groups. 1, 3
Age-Adjusted Considerations
ESR normally increases with age, requiring adjustment of reference ranges for elderly populations. 1
In elderly autopsy patients, approximately 25% had ESR values below 20 mm/h despite having significant disease (both malignant and nonmalignant), demonstrating that normal ESR does not exclude pathology in this population. 2
Clinical Context for Interpretation
Moderate elevation (50-100 mm/h) is more likely to indicate significant underlying disease. 1
ESR values exceeding 100 mm/h have 90% predictive value for serious underlying disease, most commonly infection, collagen vascular disease, or metastatic tumor. 4
In specific disease contexts, different thresholds apply:
Factors That Artificially Alter ESR
Anemia and azotemia can artificially elevate ESR values independent of inflammatory activity. 1, 3
Elevated immunoglobulins and rheumatoid factor can increase ESR without reflecting true inflammatory disease activity. 1
Body mass index significantly correlates with ESR in women with osteoarthritis but not in men or patients with rheumatoid arthritis. 6
Practical Limitations
ESR lacks both sensitivity and specificity as a screening test for disease in asymptomatic individuals. 4
In patients with osteoarthritis, 21.2% of women and 8.5% of men have ESR ≥30 mm/h without inflammatory disease. 6
If an unexplained elevated ESR is encountered, repeat testing in several months is more appropriate than pursuing exhaustive evaluation for occult disease. 4