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Hemost. & Coag - Physiology
Hemost. & Coag - Physiology
Mansyur Arif
Dept. of Clinical Pathology
Fac.of Medicine,Hasanuddin University,
Makassar
7-Nov-18 1
Regulation of hemostatic
mechanism involves complex
interaction between vessels walls,
blood cell elements and a variety
of plasma proteins.
7-Nov-18 2
Blood clotting results from :
1. Interaction between endothelial cells
and platelets the primary hemostatic
plug.
2. The coagulation phase thrombin is
generated & fibrin develops
3. Formation of peptide bonds
stabilization of the fibrin network.
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Fibrinolysis is the process of
enzymatic degradation of fibrin
clots whereby : coagulation activity
is limited to the area surrounding
vessels wall injury and patency of
vessels is maintained or restored
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PLATELET STRUCTURE
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Bilipid membrane (cont.)
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Microtubules and Microfilaments
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Dense Tubular System
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Granules
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Canaliculi
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Platelet Physiology
When a blood vessels is injured:
• Subendothelial tissue is exposed.
• PLT adhere to subendothelial tissue.
• Adherence mediated by vWf form a
bridge between subendothelial tissue
and GP Ib.
• Thrombin stimulates membrane
phospholipids to release arachidonic acid
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Platelet Physiology
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Phospholipid
Phospholipase
Arachidonic acid
Cyclo-oxygenase
(aspirin inhibits)
PGG2
Peroxidase
PGH2
Thromboxane synthetase Prostacyclin synthetase
(platelets) (endothelium)
TxA2 PGI2
H2O
TxB2 6-keto PGIa
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Coagulation phase :
1. Conversion of fibrinogen (soluble plasma
protein) into insoluble fibrin affected
by highly specific enzymatic action of
thrombin.
Thrombin must be generated from
zymogen, prothrombin, by a series of
reactions between serine proteases, co
factors & lipid moieties.
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2. Coagulation factors may be group as
follows : contact factors, thrombin -
sensitive factors, & vit K- dependent
factors.
Classically, the generation of thrombin
is described as occuring through the
“extrinsic” or “intrinsic” systems.
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Table 1. Plasma coagulation factors
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Coagulation systems :
1. The extrinsic systems : triggered by TF/
tissue factor (complete thromboplastin).
- TF + VIIa + Ca activates F X (F Xa)
- F Xa + V + Lipid (TF) extrinsic pro-
thrombinase (converts prothrombin
thrombin). (Fig 1).
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Prothrombin
TF
VIIa
(Ca 2+)
Xa
X
V
Lipid (TF)
(Ca 2+) Test : PT
(Quick)
Thrombin
Fig.1. Generation of thrombin via the extrinsic system. (TF = tissue fct ;
PT = prothrombin ; = prothrombin complex ; = F X activating
complex).
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2. The intrinsic system :
a. Contains all the elements necessary for
clotting.
b. Instead of tissue thromboplastin, the lipid
moiety in this system is PF3.
c. The contact fcts (F XII, XI, prekallikrein/PK,
High Molecular-Weight Kininogen/HMWK)
are activated by exposure to negatively
charged glass surfaces & other substances
(ellagic acid,uric acid crystals,skin,collagen
& antibody complexes)
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d. - F XIIa in the presence of PK and
HMWK activates F XI.
- F XIa activates IX, which in a complex
with VIII, lipid (PF3) and Calcium
activates F X.
- F Xa, V and lipid (PF3) comprise
“intrinsic prothrombinase”. (fig. 2).
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Contact factors Prothrombin
PK
XII XIIa
HMWK
XI
XIa IXa
IX VIII
PF3
(Ca 2+)
Xa
X V
Lipid (PF3)
Test : aPTT
(Ca 2+)
Thrombin
Fig.2. Generation of thrombin via the intrinsic system. (PK = prekallikrein; HMWK/
high molecular weight kininogen ; PF3 = platelet factor 3 ; aPTT = activated
partial thrombplastin time ; = prothrombinase complex ; = F X activa-
ting complex.
7-Nov-18 23
e. - Screening test : aPTT screens for all
the coagulation factors except F VII.
- intrinsic & extrinsic pathways
converge at the F X and V level.
- A coagulation factor deficiency (or
inhibitor) at this level results in
abnormal screening test for both
system.
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f. F VIII & V are cofactors for F IXa & Xa.
When initial traces of thrombin are genera-
ted, F VIII & V are activated (VIIIa & Va).
Larger amounts of thrombin results in
destruction of these factors. (Fig.3)
g. Interlinkage between the intrinsic & extrinsic
systems occurs at several levels. The most
important of these is the ability of TF and
factor VIIa to activate F IX. (Fig.4)
7-Nov-18 25
Prothrombin
Intrinsic system Extrinsic system
IXa
VIII VIIIa
PF3
Xa Xa
V Va Va V
PF3 TF
Thrombin
Fig.3. Autocatalytic action of thrombin. (TF= tissue fct ; PF3 = platelet fct 3)
7-Nov-18 26
Prothrombin
Intrinsic system Extrinsic system
XIa TF
VIIa
IXa (Ca2+)
IX VIII
PF3
(Ca2+)
X Xa
Thrombin
Fig. 4. Linkage between extrinsic and intrinsic systems. Several interaction
occur at various levels of the two systems. Primary among these is the
7-Nov-18 27
ability of TF and F VIIa and F IX.
3. Fibrin generation
When thrombin acts on the fibrinogen molecu-
le, two pairs of tiny fibrinopeptides (A & B) are
cleaved off, yielding “activated” fibrin mono-
mer units. The monomers polymerize to form
a loose, unstable fibrin clot, which can be
converted to a stable fibrin clot. (Fig.5)
7-Nov-18 28
Thrombin
Fibrinogen Fibrin Fibrin Polymer
monomer (hydrogen bonded)
XIIIa
Fibrin polymer Fibrin polymer
(hydrogen bonded) (peptide bonded)
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Fibrinolysis
• Deposition of fibrin is associated with activati-
on of fibinolysis
• Fibrin is a substrate for the proteolytic action
of plasmin.
• Plasmin is normally present in its inactive,
zymogen form (plasminogen) in blood, urine
and other body fluids.
• Plaminogen may be activated intrinsically by
the contact system of coagulation or extrin-
sically by TPA/tissue plasminogen activator.
7-Nov-18 33
• Exogenous activation may be induced
therapeutically by administration of
urokinase or streptokinase. (Fig.7)
• Screening Test :
TT may be prolonged due to presence
of FDP (may show elevation).
.
7-Nov-18 34
Physiologic inhibitors
• Procoagulant & fibrinolytic activities are
homeostatically regulated by counter-
balancing natural inhibitors
• In the coagulation system, antithrom-
bin III inhibits not only thrombin but
other serine protease as well (F IXa,
Xa, XIa, XIIa).
7-Nov-18 35
• Protein C along with its cofactor, protein
S, degrades F VIIIa and Va.
• Plasmin is neutralized primarily by
2 - antiplasmin.
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Plasminogen
Intrinsic system Extrinsic system
Contact
XII XIIa
HMWK
Exogenous
Plasmin
VII
IX IXa + VIII TF
Ca 2+ Ca 2+ Ca 2+
PL
X Xa + V
Ca 2+
PL
Prothrombin Thrombin
Fibrinogen Fibrin
A. Screening Test
1. Partial thromboplastin time (PTT) and
activated partial thromboplastin time (aPTT)
2. Prothrombin time (PT)
3. Quantitative fibrinogen
4. Thrombin time (TT)
5. Screening test for factor XIII
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III. CONGENITAL HEMORRHAGIC DISORDER
A. Hemophilia A (factor VIII deficiency) and
Hemophilia B (factor IX deficiency)
1. Pathophysiology :
X chromosome, gene defect.
2. Clinical features :
mild, moderate and severe disease
3. Diagnosis :
a. screening tests
b. specific factor assay
7-Nov-18 47
4. Therapy : to raise the deficient factor
a. Pharmacologic therapy :
b. Replacement therapy :
1. Physiology of vWF :
- HMW glycoprotein, 250 kD
- In plasma and in platelets
- as a carrier protein for coag. F VIII
- important for primary hemostasis
- mediates adhesion of platelets to the s.endot
- vWF – F VIII complex : F VIII : C, F VIII : Ag,
F VIII : Cag, F VIII : RCof.
7-Nov-18 50
2. Clinical features : >> mucous membrane
bleeding, epistaxis, menorrhagia
3. Diagnosis :
- Combination of prolonged BT and a
decreased F VIII : C level classically
- Combination of abnormalities of the functional
measures of the vWF – F VIII complex
variants of vWF (see table 2)
- Ristocetin aggregation
- Diff. of type F VIII multimer analysis :
type I, IIA, IIB, IIC, III.
7-Nov-18 51
Table 2. Laboratory Findings in Hemophilia A
and Severe vWF Disease
7-Nov-18 52
4. Therapy
a. dDVAP
b. Cryoprecipitate
c. F VIII concentrates
7-Nov-18 53
IV. ACQUIRED HEMORRHAGIC DISORDER
A. Vitamin K deficiency
1. Etiology
a. dietary deficiency
b. malabsorption
c. antibiotic therapy
d. hemorrhagic disease of the new born
2. Clinical features : severe bruising or
excessive bleeding or asymptomatic
7-Nov-18 54
3. Diagnosis
- severe : prolonged PT and PTT
- early or milder def. : prolonged PT
4. Therapy
- Parenteral vit. K
- FFP
B. Liver disease
1. Etiology
a. decreased synthesis of coag. factors
b. Vit. K def
7-Nov-18 55
c. Functionally abnormal fibrinogens
d. Disseminated Intravasc. Coagulation
(DIC) and consumption of coag. factors
2. Clinical features
- vary with the course of the patient’s liver
disease
- >> GIT bleeding
3. Diagnosis
- Lab. findings varies widely
7-Nov-18 56
4. Therapy
- trial of parenteral vit K therapy
- Replacement therapy FFP
C. Clotting factor inhibitors autoantibodies
1. Inhibitors in hemophilia
2. Inhibitors in patients without preexisting
bleeding disorders
a. Etiology : drugs, autoimmune or
lymphoproliferative disorders,
spontaneous a.coagulants
7-Nov-18 57
b. Diagnosis : mixing study, factor assays
c. Therapy : supportive
3. Lupus anticoagulant cardiolipin
a. Prolonged PTT, false + serologic test
b. associated with recurrent spont.abortions.
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COAGULATION REGULATION AND
HYPERCOAGULABLE STATES
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I. CONTROL MECHANISMS IN COAGULATION
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B. Fibrinolitic system
1. Activation :
a. Intrinsic activation : a poorly understood
mechanism of activation
b. Extrinsic Activation : Tissue plasminogen
activator (t-PA), urokinase
c. Exogeneous (therapeutic) activation :
streptokinase, urokinase and t-PA
7-Nov-18 61
2. Sites of action
a. Fibrinogen
b. Fibrin
7-Nov-18 62
B. AQUIRED THROMBOTIC DISORDER
THROMBOEMBOLIC DISEASE
1. Risk factors :
a. abnormalities of blood flow
b. abnormalities of the vasculature
c. abnormalities of the coagulation system
2. Clinical manifestations :
a. Venous thrombosis
- superficial thrombosis
- deep vein thrombosis
7-Nov-18 63
b. Pulmonary embolism
c. Arterial thrombosis
d. Other
4. Therapy
a. Agents treatment and prevention
1. Anticoagulants :
- Heparin
- Warfarin
2. Thrombolytic agents :
- Streptokinase
- Urokinase
7-Nov-18
- t-PA 64
b. Treatment approaches
1. Deep vein thrombosis : >> heparin,
thrombolytic agent
2. Pulmonary embolus : heparin, thrombolytic
agent
3. Myocardial infarction : thrombolytic agent
4. Peripheral artery and catheter thrombosis :
thrombolytic agent.
7-Nov-18 65
III. THROMBOHEMORRHAGIC DISORDER
7-Nov-18 70
THANK YOU
7-Nov-18 71