ESR
Evolution

[ Erythrocyte Sedimentation Rate ]

The Evolution of ESR Testing:
The Enduring Standard for Inflammatory Assessment

ESR has remained a cornerstone of inflammatory assessment for over a century. Discover how this time-tested, trusted test continues to evolve for modern clinical practice.

ESR Overview

How Does an ESR Test Work?

Erythrocyte Sedimentation Rate (ESR) is a simple, low-cost blood test that measures how quickly red blood cells settle out of the plasma when a blood sample is left to sit in a vertical column. Widely used as a general indicator of inflammation, ESR remains one of the most accessible and trusted tools in clinical diagnostics.

01
ESR reflects the tendency of red blood cells (RBCs) to aggregate and settle more rapidly in some disease states because of increased protein in the bloodstream​.
  • ESR is primary influenced by increases in acute phase reactants and fibrinogen
  • Changes in erythrocyte sedimentation can also be affected by RBC shape, number, and size
02
Increased protein in the bloodstream during inflammation disrupts the natural repelling forces between erythrocytes, resulting in rouleaux formation.
03
The more red blood cells aggregate, the more they setting during an ESR test.1
04
ESR is often used as a general "sickness indicator" due to its non-specific nature, accessibility, and relatively low cost.2

ESR in Clinical Practice

Why is an ESR test ordered?

ESR testing is a widely-used marker of subclinical, acute, and chronic inflammation that, alongside other testing & clinical findings, helps health care providers reach a diagnosis or evaluate a current condition​.

Screening

A sensitive indicator of inflammation, making it valuable for identifying underlying inflammatory conditions​

Assisting in Diagnosis

Aids in diagnosing various inflammatory and infectious diseases, especially at very high levels​

Differential Diagnosis

In conjunction with other clinical findings and laboratory tests, it helps differentiate between different disease conditions with similar symptoms (e.g. rheumatoid arthritis & osteoarthritis)​

Monitoring Therapeutic Changes

Can be monitored over time to assess a patient's response to therapy; changes in ESR values may indicate the effectiveness of treatment or disease progression, enabling timely adjustments in patient management​

ESR is a non-specific test – that means it isn’t diagnosing a specific condition. It can be helpful any time inflammation is suspected, and is intended to be used by a clinician in conjunction with clinical examination, patient history, and/or other laboratory test results​.2
CLINICAL VALUE OF ESR

What Makes ESR Unique?

ESR captures the full inflammatory signal ​

Increases in ESR values result from increases in multiple acute phase proteins – not just a single protein.​

This is unique to ESR testing – it captures a broad signal over a long window.​

Unlike other laboratory tests that detect a well-defined analyte with a specific molecular structure, ESR is measuring a “physicochemical phenomenon.”1,3

ESR Characteristics

Measures cumulative inflammation over days and weeks4

Less sensitive to short-term fluctuations than CRP5

Systemic inflammation indicator5

ESR Clinical Advantage

Useful for monitoring chronic or subacute conditions5

Monitoring chronic disease5

Increased sensitivity to diffuse, low-grade/subacute conditions5

CLINICAL VALUE OF ESR

Important ESR Use Cases

Since ESR is not specific for any disease, it can be used to assess a multitude of conditions. However, it is important to note ESR is intended to be used in conjunction with patient history, clinical exam, and/or other laboratory tests.

Common use cases where ESR is proven to have clinical advantages

Monitoring chronic inflammatory conditions

Example: ESR can be used a measure of disease activity in inflammatory bowel disease6 and for monitoring pediatric Crohn’s Disease as a scored component of the pediatric Crohn’s disease activity index (PCDAI)7

Diagnosis and monitoring of autoimmune diseases

Example: ESR is a key marker of disease activity in rheumatoid arthritis (as a component of the disease activity DA28 score)8 and system lupus erythematosus (SLE)9,10

Assessing ​subacute or chronic infections

Example: ESR can help identify inflammation in latent tuberculosis infection11 and low-virulence periprosthetic joint infection12

Assessing specific ​cancer-related situations​

Example: Elevated ESR is a marker of occult cancer13 and can be a prognostic indicator during cancer assessment14,15,16

Assessing​ cardiovascular disease risk​

Example: ESR can help predict coronary heart disease in men and women17

Assessing fever of unknown origin (FUO)​

Example: ESR can help identify FUO18 and rule out inflammatory causes19

CLINICAL VALUE OF ESR

Examples of ESR Assisting in Diagnosis

ESR is non-specific, but in some cases it is used as part of the diagnostic workup to assist in diagnosing a specific condition.

Giant Cell Arteritis (Temporal Arteritis)
  • ESR is classically very high (often >50–100 mm/hr)
  • Used as part of diagnostic workup with symptoms (headache, jaw pain) and temporal artery biopsy or imaging
  • A normal ESR doesnot fully exclude it but is uncommon20,21

Polymyalgia Rheumatica (PMR)
  • Most patients have markedly elevated ESR22​
  • ESR is part of the ACR/EULAR classification scoring system23
  • ESR alone doesn’t diagnose PMR, but it strongly supports the clinical picture (proximal stiffness, pain)​

Hodgkin Lymphoma
  • ESR is used when stratifying Hodgkin lymphoma patients into risk groups24

Multiple Myeloma
  • ESR is not diagnostic for multiple myeloma, but it is commonly markedly elevated25

→ These are some key examples – not intended to be an exhaustive list​

ESR Testing Technology

The Traditional Westergren Method

The Westergren method
The traditional Westergren method of performing ESR was developed in 1921 - a labor intensive test that takes an hour to generate a result
How it's done
Anticoagulated blood is diluted and placed in a specialized graduated vertical tube then left to sit so that the red cells can “settle” out of the plasma​
Analyzing results
At 60 minutes, the distance from the bottom of the meniscus to the top of the RBC sediment column is measured and reported out in mm/hr​
Modernization
Newer ESR methods measure earlier phases of the sedimentation process before 60 minutes

The Original ESR

ESR Testing Technology

The Evolution of ESR Testing Technology​

Erythrocyte sedimentation is a mulit-phase process.​

The amount of RBC sedimentation is directly correlated to the amount of RBC aggregation.​

Modern ESR testing methods based on photometric rheology measure RBC aggregation – the first step of RBC sedimentation – and can generate an ESR result in seconds via an automated analyzer.​

ESR Testing Technology

New Technology Offers Real-World Sample Stability

The Westergren method and other sedimentation-based ESR methods have always had the limitation of a short window of sample stability – samples must be tested or refrigerated within just 4 hours. After 4 hours, samples degrade and results can be affected.1 This is a major challenge for a routine blood test when collection sites are dispersed and courier transport systems cannot guarantee temperature control. Newer photometric rheology-based ESR systems increase sample stability to 28 hours at room temperature and 48 hours refrigerated – improving ESR reliability, reproducibility, and laboratory logistics.

Sedimentation-Based ESR Analyzers

4 hour room temperature stability

24 hour refrigerated stability

Photometric Rheology ESR Analyzers

28 hour room temperature stability

48 hour refrigerated stability

ESR Testing Technology

Modern ESR Testing Allows For...

Longer sample stability​

Westergren-based ESR tests only have 4 hours of room temperature stability; modern ESR methods allow for 7x longer stability – improving result reliability and patient care​

Reproducible results​

Testing process is fully automated to reduce operator error and subjectivity and improve traceability​

Results within 20 seconds​

Truly STAT ESR results are possible​

Reduced exposure to environmental variables​

Sample analysis occurs in a closed system​

Increased throughput​

The rapid time to result and higher capacity analyzers allow for high volume testing​

Full automation​

Fully automated procedure improves lab efficiency and productivity by freeing up valuable tech time​

Smaller sample size​

Dedicated or separate ESR tubes are not necessary; the same tube can be used for other hematology tests​

Less risk of exposure to biohazards​

No uncapping of sample tube or disposables involved​

Comparing ESR and CRP​

How is ESR Different than CRP?

Like ESR, CRP is a non-specific marker of inflammation and should be used in combination with clinical history and physical examination.

Comparing ESR and CRP​

ESR and CRP are Complementary

ESR and CRP have fundamentally different kinetics – making them complementary, NOT interchangeable​.5,26

The case for retaining ESR alongside CRP:​

  • ESR has a unique kinetic profile complementary to CRP5,26
  • ESR detects inflammatory disorders not detected by clinical examination or CRP27
  • ESR better reflects cumulative inflammation over days to weeks, useful for chronic or subacute conditions5,28
  • ESR is more sensitive to diffuse, low-grade/subacute conditions, indicating systemic inflammation29
  • ESR is less sensitive to short term fluctuations and more stable in chronic disease monitoring5
  • ESR can improve clinical decision-making when results are discordant with CRP30
Comparing ESR and CRP​

Diagnostic accuracy of ESR vs. CRP

One is not definitively more clinically accurate than the other​. Both are non-specific and should be used in conjunction with other lab tests or other findings.

Clinical performance varies based on28,31:

  • The patient
  • Disease state
  • How the test is used (i.e. during screening, for monitoring, for prognosis)
  • Timing of the test (used in early or late state of the disease?)
  • Other factors such as sample or pre-analytical variables
Comparing ESR and CRP​

ESR and CRP Discordance

High CRP, Normal ESR

Possible causes include:

  • Acute infection/inflammation (CRP rises fast; ESR lags)​
  • Myocardial infarctions​
  • Venous thromboembolism34
  • Obesity (can also raise ESR)35

High ESR, Normal CRP​

Possible causes include:

  • Connective tissue diseases (i.e. systemic lupus erythematosus - SLE)​
  • Low grade bone and joint infections​
  • Ischemic stroke​
  • Chronic inflammatory states / Low-grade chronic inflammation34
  • Multiple myeloma36 and other malignancies37

Very early or very late inflammatory states may also exhibit discordant results.

Economic Impact

Economic Impact of ESR Testing

There is evidence combining ESR and CRP testing may result in cost savings to the health system vs. CRP alone.

The Evidence at a Glance

  • Two separate health economics studies31,38 in Canada and the US have demonstrated that testing ESR + CRP together helps reduce misdiagnoses compared to CRP testing alone, particularly false positives.
  • In the US, automated ESR testing only costs payers $2.7038 – minimal cost for more clinical insights. The actual laboratory costs for an ESR test are even lower.
  • At an average size US hospital, an ESR+CRP testing strategy – vs. CRP alone – could save a hospital $9.95M annually.38
  • There is evidence that the ESR + CRP testing strategy is a cost-effective strategy for reducing misdiagnoses and results in a net cost reduction to the healthcare system when accounting for the reduction in follow-up costs associated with misdiagnoses.38

The value of choosing both ESR + CRP

$2.70
Incremental US payer cost for an ESR test​
$9.95M
Annual potential savings/hospital​
Final takeway

Erythocyte Sedimentation Rate...

  • Provides unique clinical value across multiple patient populations​
  • Has been modernized to streamline testing efficiency​
  • Can be used in combination with CRP to reduce misdiagnoses and follow-up testing costs​
Download a free summary of the value of ESR​
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References

  1. Clinical and Laboratory Standards Institute. Procedures for the Erythrocyte Sedimentation Rate Test; Approved Standard. 5th ed. Wayne, PA: Clinical and Laboratory Standards Institute; 2011. CLSI document H02-A5.​
  2. Kahar MA. Erythrocyte sedimentation rate (with its inherent limitations) remains a useful investigation in contemporary clinical practice. Ann Pathol Lab Med. 2022;9(6):R9-R17. doi:10.21276/apalm.3155​
  3. Kratz A, Plebani M, Peng M, Lee YK, McCafferty R, Machin SJ. ICSH recommendations for modified and alternate methods measuring the erythrocyte sedimentation rate. Int J Lab Hematol. 2017;39(5):448-457. doi:10.1111/ijlh.12693​
  4. Harrison M. Erythrocyte sedimentation rate and C-reactive protein. Aust Prescr. 2015;38(3):93-94. doi:10.18773/austprescr.2015.034​
  5. Litao MKS, Kamat D. Erythrocyte sedimentation rate and C-reactive protein: how best to use them in clinical practice. Pediatr Ann. 2014;43(10):417-420. doi:10.3928/00904481-20140924-10​
  6. Sachar DB, Smith H, Chan S, Cohen LB, Lichtiger S, Messer J. Erythrocytic sedimentation rate as a measure of clinical activity in inflammatory bowel disease. J Clin Gastroenterol. 1986;8(6):647-650. doi:10.1097/00004836-198612000-00011​
  7. Hyams JS, Ferry GD, Mandel FS, et al. Development and validation of a pediatric Crohn’s disease activity index. J Pediatr Gastroenterol Nutr. 1991;12(4):439-447. doi:10.1002/j.1536-4801.1991.tb10268.x​
  8. Prevoo MLL, van ‘t Hof MA, Kuper HH, van Leeuwen MA, van de Putte LBA, van Riel PLCM. Modified disease activity scores that include twenty-eight-joint counts: development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum. 1995;38(1):44-48. doi:10.1002/art.1780380107​
  9. Vilá LM, Alarcón GS, McGwin G Jr, Bastian HM, Fessler BJ, Reveille JD; LUMINA Study Group. Systemic lupus erythematosus in a multiethnic cohort (LUMINA): XXIX. Elevation of erythrocyte sedimentation rate is associated with disease activity and damage accrual. J Rheumatol. 2005;32(11):2150-2155.​
  10. Stojan G, Fang H, Magder L, Petri M. Erythrocyte sedimentation rate is a predictor of renal and overall SLE disease activity. Lupus. 2013;22(8):827-834. doi:10.1177/0961203313492578​
  11. Selvavinayagam ST, Anusree A, Yong YK, et al. Clinical laboratory analytes and platelet-associated parameters as surrogate markers of subclinical inflammation in latent tuberculosis infection. Front Immunol. 2025;16:1662454. doi:10.3389/fimmu.2025.1662454​
  12. Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469(11):2992-2994. doi:10.1007/s11999-011-2102-9​
  13. Kornum JB, Farkas DK, Sværke C, Severinsen MT, Thomsen RW, Sørensen HT. Cancer risk and prognosis after a hospital contact for an elevated erythrocyte sedimentation rate. Cancer Epidemiol Biomarkers Prev. 2019;28(1):225-232. doi:10.1158/1055-9965.EPI-18-0376​
  14. Abdollahi O, Vosoughi T, Talebi A, Karimpourian H, Rastegar M, Farhadi E. Investigation of ESR values in the diagnosis of malignancies: a cross-sectional study. Health Sci Rep. 2025;8(9):e71208. doi:10.1002/hsr2.71208​
  15. Wu S, Zhou Y, Hua HY, et al. Inflammation marker ESR is effective in predicting outcome of diffuse large B-cell lymphoma. BMC Cancer. 2018;18:997. doi:10.1186/s12885-018-4914-4​
  16. Johansson JE, Sigurdsson T, Holmberg L, Bergström R. Erythrocyte sedimentation rate as a tumor marker in human prostatic cancer: an analysis of prognostic factors in 300 population-based consecutive cases. Cancer. 1992;70(6):1556-1563. doi:10.1002/1097-0142(19920915)70:6<1556::aid-cncr2820700617>3.0.co;2-3​
  17. Andresdottir MB, Sigfusson N, Sigvaldason H, Gudnason V. Erythrocyte sedimentation rate, an independent predictor of coronary heart disease in men and women: the Reykjavik Study. Am J Epidemiol. 2003;158(9):844-851. doi:10.1093/aje/kwg222​
  18. Mulders-Manders C, Simon A, Bleeker-Rovers C. Fever of unknown origin. Clin Med (Lond). 2015;15(3):280-284. doi:10.7861/clinmedicine.15-3-280​
  19. David A, Quinlan JD. Fever of unknown origin in adults. Am Fam Physician. 2022;105(2):137-143.​
  20. Johns Hopkins Vasculitis Center. Giant cell arteritis. Accessed November 18, 2025. https://www.hopkinsvasculitis.org/types-vasculitis/giant-cell-arteritis/​
  21. Ponte C, Grayson PC, Robson JC, et al. 2022 American College of Rheumatology/EULAR classification criteria for giant cell arteritis. Arthritis Rheumatol. 2022;74(12):1881-1889. doi:10.1002/art.42325​
  22. Dasgupta B, Cimmino MA, Maradit-Kremers H, et al. 2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis. 2012;71(4):484-492. doi:10.1136/annrheumdis-2011-200329​
  23. RheumCalc Criteria. 2012 American College of Rheumatology/European Alliance of Associations for Rheumatology classification criteria for polymyalgia rheumatica. Accessed November 18, 2025. https://rheumcalc.com/pmr/index.php​
  24. German Hodgkin Study Group. Disease stages and risk factors. Accessed November 18, 2025. https://en.ghsg.org/disease-stages​
  25. Koshiaris C, Van den Bruel A, Oke JL, Nicholson BD, Shephard E, Braddick M, Hamilton W. Early detection of multiple myeloma in primary care using blood tests: a case-control study in primary care. Br J Gen Pract. 2018;68(674):e586-e593. doi:10.3399/bjgp18X698357​
  26. Mantovani A, Garlanda C. Humoral innate immunity and acute-phase proteins. N Engl J Med. 2023;388(5):439-452. doi:10.1056/NEJMra2206346​
  27. Singh G. C-reactive protein and erythrocyte sedimentation rate: continuing role for erythrocyte sedimentation rate. Adv Biol Chem. 2014;4(1):5-9. doi:10.4236/abc.2014.41002​
  28. Lapić I, Padoan A, Bozzato D, Plebani M. Erythrocyte sedimentation rate and C-reactive protein in acute inflammation: meta-analysis of diagnostic accuracy studies. Am J Clin Pathol. 2020;153(1):14-29. doi:10.1093/ajcp/aqz142​
  29. Kelly R, Nocito R. Erythrocyte sedimentation rate and C-reactive protein in the ED. emDocs. Published May 29, 2023. Accessed July 16, 2026. https://www.emdocs.net/erythrocyte-sedimentation-rate-and-c-reactive-protein-in-the-ed/​
  30. Costenbader KH, Chibnik LB, Schur PH. Discordance between erythrocyte sedimentation rate and C-reactive protein measurements: clinical significance. Clin Exp Rheumatol. 2007;25(5):746-749.​
  31. Canadian Agency for Drugs and Technologies in Health (CADTH). Comparative value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) testing in combination versus individually for the diagnosis of undifferentiated patients with suspected inflammatory disease or serious infection: a systematic review and economic analysis. CADTH; 2015. CADTH Health Technology Assessment No. 140. Accessed July 16, 2026. https://www.ncbi.nlm.nih.gov/books/NBK333365/​
  32. Watson J, Jones HE, Banks J, Whiting P, Salisbury C, Hamilton W. Use of multiple inflammatory marker tests in primary care: using Clinical Practice Research Datalink to evaluate accuracy. Br J Gen Pract. 2019;69(684):e462-e469. doi:10.3399/bjgp19X704309​
  33. Colombet I, Pouchot J, Kronz V, Hanras X, Capron L, Durieux P, Wyplosz B. Agreement between erythrocyte sedimentation rate and C-reactive protein in hospital practice. Am J Med. 2010;123(9):863.e7-863.e13. doi:10.1016/j.amjmed.2010.04.021​
  34. Feldman M, Aziz B, Kang GN, Opondo MA, Belz RK, Sellers C. C-reactive protein and erythrocyte sedimentation rate discordance: frequency and causes in adults. Transl Res. 2013;161(1):37-43. doi:10.1016/j.trsl.2012.07.006​
  35. Reuters Health. Obesity associated with increased inflammatory markers in rheumatoid arthritis. The Rheumatologist. Published September 28, 2023. Accessed November 24, 2025. https://www.the-rheumatologist.org/article/obesity-associated-increased-inflammatory-markers-rheumatoid-arthritis/​
  36. Koshiaris C, Van den Bruel A, Oke JL, et al. Early detection of multiple myeloma in primary care using blood tests: a case-control study in primary care. Br J Gen Pract. 2018;68(674):e586-e593. doi:10.3399/bjgp18X698357​
  37. Bray C, Bell LN, Liang H, et al. Erythrocyte sedimentation rate and C-reactive protein measurements and their relevance in clinical medicine. WMJ. 2016;115(6):317-321. ​
  38. Yarnoff B, Morris W, Zivaripiran H, McCutcheon M, Koshy T. Economic evaluation of combined testing strategies using erythrocyte sedimentation rate and C-reactive protein tests. Clinicoecon Outcomes Res. 2026;18:578961. doi:10.2147/CEOR.S578961​

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