Professional Documents
Culture Documents
Coagulation and The Clotting Cascade
Coagulation and The Clotting Cascade
almostadoctor.co.uk/encyclopedia/clotting-cascade
Dr Tom Leach
Introduction
Coagulation is the process by which blood changes from a liquid into a blood clot, to
cause the cessation of blood loss from a blood vessel.
The process involves the activation, adhesion and aggregation of platelets, and the
deposition of fibrin.
Haemostasis
Haemostasis – is the technical name for the cessation of bleeding, and has 3 separate
stages:
In reality, these are not distinctly separate, and all occur simultaneously as a result of
multiple cascades.
ADP
Tissue Factor – aka factor III – required for the activation of thrombin from
prothrombin
Prostacyclin – kind of a feedback mechanism; thisprotein actually causes
vasodilation and prevents formation of the platelet plug
Endothelins – these are the primary hormones involved in the vascular phase.
They stimulate smooth muscle contraction and stimulate cell division of endothelial
cells, smooth muscle cells and fibroblasts, thus aiding repair of the damaged site.
1/13
Endothelial cells also become ‘sticky’ and will express surface proteins that allow them to
‘stick’ to other endothelial cells, in an attempt to close of the damaged area.
Contain actin and myosin, and as a result are actually able to contract
They also contain another contractile protein known as thrmobosthenin
Have no nucleus, and are thus not able to reproduce
Have a large ER and golgi apparatus for storage of calcium ions
Have plenty of mitochondria for formation of ATP
Produce plenty of prostaglandins and fibrin-stabilising factor
Produce platelet derived growth factor (PDGF) – which helps vascular repair
Produce thromboxane A2 – which is a prominent vasoconstrictor
They are actually cell fragments rather than actual cells – as during their
development, their precursors break down to form them
Have a special glycoprotein membrane that prevents adhesion to normal
epithelium, but that promotes adhesion to damaged epithelium. they are
particularly adherent to collagen – which will only be present when deep areas
of the cell wall are exposed
About 1/3 of platelets are stored in the spleen and other vascular organs at
any one time – waiting to be mobilised
Low platelet count – thrombocytopaenia – this is a process either of high
platelet destruction, or low platelet production.
High platelet count – thrombocytosis – this is usually a result of increased
platelet formation, most commonly seen in response to infection, inflammation,
and cases of cancer.
2/13
It will swell, and become large and irregular
The contractile proteins contract causing the release of granules…
ADP, thromboxane and Ca2+ ions are all released – these can act on nearby
platelets, and attract them to the site, causing them to adhere to the platelets
already present. This creates a positive feedback loop, causing aggregation of
more and more platelets.
α – these contain growth factors, like fibrinogen and PDGF – a disease caused by
a lack of α granules is called grey platelet syndrome. This is a rare genetic
disorder (autosomal dominant) that causes. It will just basically cause reduced
clotting.
Dense – these contain non-protein things, like thromboxane, serotonin, adrenaline,
histamine, calcium, ATP and ADP
Fibrinogen is soluble, but fibrin is insoluble, and thus once fibrin becomes activate
it begins to ‘precipitate’ out of the plasma.
Activated fibrin will basically entangle platelets, and passing red blood cells in a big
nasty ball – a blood clot!
Note that – once activated, thrombin can act as a ‘catalyst’ in other areas of the
cascade to speed up the process:
It can activate factor VII directly
It activates factor V
The extrinsic pathway produces thrombin very quickly, but in small amounts, the
intrinsic pathway produces a large amount of thrombin, but takes a while to get
going.
4/13
thrombin, thus preventing its action. It is crucial for the action of heparin!
Activated fibrin will remove and inactivate thrombin. About 85-90% of the thrombin
produced is inactivated in this way.
5/13
The Clotting Cascade
Heparin
This combines with antithrombin-III, and force a conformational change in the
compound, so that it acts at various stages of the clotting cascade to reduce clotting. It
increases the effectiveness of antithrombin-III by over 1000x.
Mechanism of action
Heparin does not act directly on the extrinsic pathway.
It will inactivate many of the factors produced in clotting:
2, 8, 9, 10, 11, 12 are the ones affected (thrombin and 8-12!)
It will also encourage the release of TFPI
Pharmacokinetics
Heparin is available as unfractioned heparin (‘normal’ heparin) or in various low
molecular weight preparations.
Note that heparin can be inactivated by nicotine!
Unfractioned Heparin
HL – approx 30 minutes – but this is unpredictable! It can increase to up to 2-3 hours
with larger doses.
The majority of heparin is metabolised by endothelial cells – hence its unpredictability.
The rest is mainly metabolised by the liver, and some is excreted by the kidney. The half-
life gets longer the greater the amount of drug you use because once you get past the
‘saturation point’ the endothelial cells can no longer cope with the drug, and thus slower
mechanisms, such as renal excretion are the primary method of metabolism, until the
level of drug drops below the saturation point again.
It can be given either subcutaneously or intravenously:
Subcutaneous – low doses are often given in this manner. Bio-availability is only
about 30% when you give it by this route though, so it is not good for large doses
or emergencies (i.e. PE). It also takes up to an hour before the action of the drug is
seen.
Intravenous – more rapid (immediate), and much greater bioavailability. Thus in
the emergency situation, it is often given as an initial IV dose, followed by
subcutaneous infusion.
6/13
LMWH
Low molecular weight heparin – e.g. clexane (enoxaparin), Dolteparin, Nadroparin
These have approximately 2x the duration of action (HL), and are far more
predictable than unfractioned heparin.
They have a lower affinity for binding sites (particularly the binding sites on
endothelial cells) than unfractioned heparin, hence the greater duration of action
and greater predictability.
Note that this will also mean that more of the heparin is metabolised by the
liver than when you give unfractioned heparin.
They have a greater effect on factor Xa, than on IIa, which suggests that they
produce an equal anti-coagulant effect to heparin, but that they have a reduced
risk of causing bleeding – therefore good news all round!
Nice to know
Heparin is found naturally in the body in small amounts and is produced by mast cells
and basophils.
Mast cells and basophils – basically the same cells, but mast cells are found in
connective tissue, and basophils are found in the blood stream.
Heparin is not actually one specific substance, the name actually encompasses a family
of glycosaminoglycans, commercially it is extracted from beef lung or hog intestines, and
due to variability of its potency, the drug is measured in standardised units, and not
mass or volume.
Vitamin K antagonsists– note that the ‘K’ stands for Koagulation in German!
e.g. warfarin
Vitamin K is a fat soluble vitamin, that occurs naturally in plants. It is essential for the
7/13
formation of clotting factors 2, 7, 9 & 10. Proteins C and S are also dependent on
vitamin K.
Warfarin
It is the most important oral anticoagulant. Other examples with a similar mechanism of
action include pheninidione.
Patients on warfarin (and other vit K antagonists) need to have individualised doses, and
this means the treatment in both inconvenient and has a low margin of safety.
Mechanism
Inhibits enzymatic reduction of vitamin K to its active form – hydroquinone. Binding is
competitive.
The effect takes several days to develop, as it is dependent on the half life of the already
active factors, 2, 7, 9 and 10.
VII – has a half life of 6 hours
IX – has a half life of 24 hours
X – has a half life of 40 hours
II – has a half life of 60 hours
Pharmacokinetics
Absorbed rapidly and completely from the gut
Binds well to albumin
Peak time of action is about 48 hours after administration, but peak concentration
in the blood is about an hour after administration
The effect on prothrombin time is initially seen after 12-16 hours, and lasts
approximately 4-5 days.
Half life is very variable, but is on average about 40 hours
It crosses the placenta, and is teratogenic – thus it should not be given in
pregnancy at all! In the early stages it can causes defects, and in the later stages it
can cause haemorrhages in the foetus itself – usually intracranial haemorrhage.
It is metabolised by the cytochrome P450 system – thus it interacts with many
drugs – making administration and monitoring of dosage more difficult.
Warfarin is monitored by using the prothrombin time (PT), which is expressed as
the INR. The dose of warfarin is adjusted to give an INR of 2-4
Unwanted effects
Haemorrhage – this is especially common to the bowel and brain. This can be
counteracted by the administration of vitamin K, or giving fresh plasma containing
clotting factors.
Teratogenicity (causes birth defects)
8/13
Necrosis of soft tissues – this occurs mainly to tissues in the buttock and breast
and is a result of thrombosis in venules. It generally occurs shortly after
administration, and is a result of inhibition of synthesis of protein C – which is
another effect of warfarin, and which happens more quickly than the inhibition of
activation of vit K. thus for a short time after the initial administration, patients are
in a hypercoagulant state. This is rare, but serious.
To combat this issue, treatment is usually started with heparin, before treatment
with warfarin begins.
Drugs
Agents that inhibit hepatic metabolism – such as many antifungals, and other
specific drugs, including cimetidine, ciprofloxacin, chloramphenicol, co-
trimoxazole, imipramine, metronidazole and amiodarone.
Drugs that inhibit platelet function – Aspirin, and other NSAIDs – as these inhibit
platelet thromboxane synthesis. Also some antibiotics, including moxalactam and
carbenicillin
Drugs that displace warfarin from its binding site on albumin – e.g. NSAIDs and
chloral hydrate – as this will increase the concentration of warfarin in plasma
Drugs that inhibits synthesis of vitamin K – such as the cephalosporins
Drugs
Vitamin K – it is found in some vitamin preparations and some form of parenteral
feeding
Drugs that induce hepatic cytochrome P450 enzymes – this increases the
degredation of warfarin. Examples include rifampicin, carbamazepine,
barbiturates and griseofulvin
Nice to know
Named after the Wisconsin Alumni Research Foundation – after cows feed was
changed in the USA, to contain sweet clover, and loads of cows died from
haemorrhagic stroke.
9/13
Warfarin acts on the extrinsic pathway, whilst heparin acts on the intrinsic
pathway. Thus, warfarin efficacy is monitored using the INR – which utilises the
prothrombin time. This is because warfarin acts on the extrinsic pathway – and the PT
is a measure of the extrinsic pathway. Remember that the extrinsic pathway produces
a bit of fibrin quickly whilst the intrinsic pathway produces large amounts but takes a
while to get going. Thus the PT, which is a measurement of how quickly a small clot
forms, relies on the extrinsic pathway.
Heparin is measured using the aPPT. This is the activated partial thromboplastin
time. This measures the intrinsic and common pathways.
Method – similar to the PT – a sample is taken, then mixed with some proteins,
and the time measured until a clot forms. The clot takes longer to form than in PT,
because the fluid that the blood is mixed with to stimulate clot formation has no
tissue factor (III) and thus the extrinsic pathway is not activated. The word ‘partial’
is used to indicate the lack of tissue factor.
The value obtained is normally between 25 and 39 seconds. A prolonged APPT can
be caused by:
Use of heparin
Haemophilia – coagulation factor deficiency
Altepplase is given as a long infusion of 3-24hr due to its short duration of action
patients will also be given 48hrs of heparin to prevent re-occulsion, again, a result
of the short half-life of the compound.
Reteplase is given as two bolus injections, and tenectplase as a single bolus.
Although there is little evidence to support it; heparin is also given with these
compounds (although a guess it would be given anyway in situations involving
clot! Just not necessarily for reasons related to the –plases.
11/13
Unwanted effects
Haemorrhage – is usually minor, but can occasionally be serious, eg. Intracerebral
haemorrhage. Other haemorrhagic complications may involve GI bleeds and stroke.
This occurs with about 1% of those treated. It occurs slightly more frequenctly with
the –plases compared to streptokinase.
The bleeding can be stopped by antifibrinolytic drugs, or y giving fresh plasma
(which is full of nice clotting factors).
For both of these drugs, the theoretical risk of thrombotic tendency does not appear to
be a clinical issue
Related Articles
Comparison and Summary of White Cell Disease
Deep Vein Thrombosis – DVT
DVT Exam
Other Coagulation Factor Deficiencies
Polycythaemia Vera
13/13