Chapter 12

Hemostasis and Coagulation

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 Introduction to Hemostasis

Maintaining the overall vascular integrity

Important Aspects
 Vasculature
 Platelets
 Coagulation proteins
 Fibrinolytic proteins

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 Introduction to
Hemostasis
 Primary hemostasis results in the formation of a platelet
plug.

 Secondary hemostasis results in the formation of a blood

clot because coagulation factors present in the blood
interact, forming a fibrin network and a thrombus, to stop
the bleeding completely.

 Tertiary hemostasis is the breakdown and removal of the

clot

 Unbalanced system leads to bleeding or thrombosis

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 Hemostatic Mechanism
• There are three components of the entire hemostatic
mechanism:
1. Extravascular effects: 1)muscle, skin, and elastic tissue close
and seal the injured vessel;2) Tissue Factors (TF)react with
plasma and platelet in the Extrinsic Pathway factors
2. Vascular effects: Vascular endothelium is inert and non-
coagulation stimulating. When disrupted: 1) the collagenous
material basement membrane exposed, causing platelet
aggregation; 2) vasoconstriction.
3. Intravascular effects: Platelets and coagualtion proteins lead to
fibrin clot. Intrinsic Pathway activated

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 Platelets

Functions of Platelets
1. React to injury of vessels by forming a platelet plug: when exposed
to collagen, become activated, adhere, and aggregate. Assisted
(acts like glue) by Fibronectin and von Willerbrand Factor
(VIII:vWF).
2. Activate and participate in plasma coagulation: secrete substances
that promote vasoconstrictio to form thrombin., platelet
aggregation, and vessel repair. Platelet Factor 3 (PF3) activates
certain coagulation factors.
3. Maintain the endothelial lining of the blood vessels: Platelet-
derived Growth Factor (PDGF)

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 Quantitative Platelets Disorders

 Thrombocytopenia: N= 150-450 X 109/L

 <100= petechiae or purpura
 <50= critical!
 3 categories
◆ 1) Disorders of production
◆ 2) Disorders of destruction or utilization
◆ 3) Disorders of distribution and dilution.

 Thrombocytosis

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 Coagulation

 There are four major steps in the mechanism of

coagulation: Plasma proteins, coagulation
factors, TFs, and calcium work together on the
platelet surface to form a fibrin clot.
1. Formation of thromboplastin
2. Formation of thrombin
3. Formation of fibrin
4. Fibrinolysis

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 Coagulation Factors
 All protein except calcium and phospholipid
 Roman numerals for main 12 (in order of discovery, not order in
pathways); names for others
 3 categories: substrates; cofactors; enzymes
 Fibrinogen (I): soluble precursor of fibrin/ synthesized in liver/ 2
peptides are split off by thrombin, forming a fibrin monomer that
aggregates to form polymerized fibrin clot [12-3]
 Factor VIII: 2 functional sub-units:
-Factor VIII:C- genetic deficiency= Hemophilia A; severe abnormal
bleeding; replacement therapy
-Factor VIII:VWF: genetic deficiency= von Willerbrand Disease; usually
less severe
 Factor IX: Hemophilia B; mild to severe
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 Coagulation

*When factors have been activated, they have the designation “a” after the Roman numeral. 9
 Coagulation

 Based on their properties, coagulation factors

can be divided into three groups:
1. Fibrinogen group (thrombin sensitive): factors I, V,
VIII, and XIII
2. Prothrombin group (vitamin K dependent): factors
II, VII, IX, and X
3. Contact group: factors XI and XII, prokallikrein
(Fletcher factor), and HMWK (Fitzgerald factor)

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 Coagulation

The mechanism of coagulation has three major

stages:
Stage 1: Generation of thromboplastin activity
Stage 2: Generation of thrombin
Stage 3: Conversion of fibrinogen to fibrin

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 Pathways for Coagulation Cascade

Intrinsic* versus Extrinsic Coagulation Pathway

 Intrinsic Pathway (Activation of Coagulation

Factor X)
 Activated by collagen on contact factors XI and

XII from tissue and/or vessel injury

 Major coagulation activity in the body

 Monitored by Activated Partial Thromboplastin

Time (APTT)

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 Pathways for Coagulation Cascade

 Extrinsic Pathway* (Activation of Coagulation

Factor X):
 “Extrinsic” because stimulated by tissue

thromboplastin which is not in the blood.

 Monitored by Prothrombin Time (PT)

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 Pathways for Coagulation Cascade

Common Pathway (Formation of Fibrin Clot from

Coagulation Factor X)
Fibrin clot and clot retraction: initiated by
platelets

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Intrinsic Pathway Extrinsic Pathway
FVII
TF
FVIIa
FXI FXIa
TF-FVIIa
Intrinsic Tenase Complex
Extrinsic Tenase Complex

FIX FIXa Ph & Ca2+

Ph & Ca2+
FVIII FVIIIa

FX FXa Common Pathway

Prothrombinase Complex
Ph & Ca2+ FVa FV

Prothrombin Thrombin

FXIII
Fibrinogen Fibrin (m)
Coagulation
FXIIIa
Fibrin (p)
 Fibrinolysis

System by which fibrin clot is removed and flow of

blood reestablished
Starts as soon as clotting has begun
Plasminogen converted to Plasmin which is an
enzyme which digests the fibrin clot
Fibrin split products are removed by phagocytic
cells
D-dimers: fibrin break down products when fibrin
has been stabilized by factor XIII
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 Fibrinolysis

 Several important biological activities normally

protect the body against thrombosis [12-4]:
1. Normal flow of blood
2. Removal of activated clotting factors and
particulate matter
3. Natural in vivo anticoagulant systems:
antithrombin III (AT-III), heparin cofactor II (HC-II),
and protein C [genetic disorder= factor V Leiden
(thrombophilia)]and its cofactor, protein S
4. Cellular regulators
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Intrinsic Pathway Extrinsic Pathway
Fibrinolysis
FVII
TF
FVIIa
FXI AT
FXIa TFPI
TF-FVIIa
Intrinsic Tenase Complex
Extrinsic Tenase Complex
AT
FIX FIXa Ph & Ca2+
PC-PS Ph & Ca2+
FVIII FVIIIa

AT
FX FXa Common Pathway
PC-PS
Prothrombinase Complex
Ph & Ca2+ FVa FV
AT
Prothrombin Thrombin

FXIII
tPA Fibrinogen Fibrin (m)
Plasminogen Plasmin
FXIIIa
Fibrin (p)
 Anticoagulant Therapy

 Heparin:
 initial therapy for quick anticoagulation (IV) – Unfractionated Heparin (UFH)
 Subcutaneous injection – Low Molecular Weight Heparin (LMWH)
 Warfarin (vitamin K antagonist): long term, oral
 Direct Thrombin Inhibitors (DTI): (IV) bind and inhibit
thrombin directly
 Direct Oral Anticoagulants
 Apixiban, Rivaroxaban, Edoxaban, Dabigatran

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 Anti-Platelet

Oral
 aspirin
 Ibuprofen

 Thienopyridines (P2Y12 inhibitors)

IV
 GP IIb/IIIa inhibitors
 abcixmab
 Tests for Hemostasis and
Coagulation
 Tests for Plasma Coagulation Factors
 Screen= APTT/ PT/ TT
 Definitive= specific factor involved
 Specimens for Coagulation Tests
◆ Anticoagulants: Sodium citrate (blue top)/ binds Ca ions/
reversible
◆ Centrifugation
 Platelet-poor plasma
 Platelet-rich plasma

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 Tests for Hemostasis and
Coagulation
• Performance of Coagulation Assays
• Quality Control: normal and abnormal controls
• Prothrombin Time (PT)
• Best screen for Extrinsic Pathway/monitor Warfarin
• Automated Prothrombin Assays: N= 10-13 sec.

• Reporting Prothrombin Results: International Normalized

Ratio(INR) for standardization: N= 0.9-1.13
• INR = (patient PT/standard PT)^ISI

Activated Partial Thromboplastin Time(APTT)

• Best screen for Intrinsic Pathway/ monitor Heparin

• Reporting Results: N=<35 sec

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 Tests for Hemostasis and
Coagulation
 D-Dimer Assay
• DIC (Disseminated Intravascular Coagulation)
• VTE
 Other Tests for Coagulation:
-Anti-Xa Assay: monitor heparin
 Thrombin Time (TT): measures ability of

fibrinogen to form fibrin

 Activated Clotting Time (ACT): monitor high-

dose heparin therapy (cardiac cath or bypass

surgery) 23
 Tests for Hemostasis and
Coagulation
Point-of-Care Tests for Coagulation Assays
 Quick turn-around-time (TAT)/ home

monitoring
 Coagulation Analyzers

 Quality Control: normal and abnormal controls

during each 8-hour shift (CLIA-overseen by lab)

 Problems and Drawbacks

 Training of Users: by lab

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