BLOOD CLOTTING MECHANISM; COAGULATION AND ANTI-

COAGULATION PHYSIOLOGY

Department of Physiology
Faculty of Basic Medical Sciences

Folawiyo, M.A.
 OUTLINE
• INTRODUCTION

• MECHANISMS OF BLOOD CLOTTING

PRIMARY
SECONDARY

• ANTICLOTTING MECHANISM IN THE BODY

• TEST FOR BLOOD CLOTTING

• PATHOPHYSIOLOGY
 Introduction
Blood is a necessary component of the human body,
and the loss of this fluid may be life-threatening.

Coagulation, also known as clotting, is the process

by which blood changes from a liquid to a gel,
forming a blood clot. It potentially results in
hemostasis, the cessation of blood loss from a
damaged vessel, followed by repair.

The human body protects against loss of blood

through the clotting mechanism.
 Introduction con`d
Vascular mechanisms, platelets, coagulation
factors, prostaglandins, enzymes, and proteins are
the contributors to the clotting mechanism which
act together to form clots and stop a loss of blood.

The cellular components of the clotting

mechanism include platelets, endothelial cells,
and a series of proteins, enzymes, and ions.
The clotting mechanism involves the circulatory
system which includes the lineage of blood cells
(generated via hematopoiesis and ultimately
becomes the delivery method for oxygen to the
tissues and cells) and blood vessels.
 Mechanism
The clotting mechanism is broken into 2 stages:
A. Primary hemostasis: Formation of a weak platelet plug; 4 phases
i. Vasoconstriction
ii. platelet adhesion
iii. platelet activation and
iv. platelet aggregation.

B. Secondary hemostasis: Stabilizing the weak platelet plug into a

clot by the fibrin network
This is accomplished by completing three tasks
(1)triggering activation of clotting factors
(2)conversion of prothrombin to thrombin, and
(3)conversion of fibrinogen to fibrin.  
 Mechanisms cont`d
i. Vasoconstriction: is the initial response whenever there is vessel
injury.
 This is seen as vasospasm of the blood vessels, which in turn,
stimulates vasoconstriction.
 Vasoconstriction is primarily mediated by endothelin-1, a potent
vasoconstrictor, which is synthesized by the damaged endothelium.
 Damaged endothelium exposes sub-endothelial collagen, von
Willebrand factor (vWF), releases ATP, and inflammatory mediators.
 vWF is synthesized by megakaryocytes which later gets stored in a-
granules of platelets. Weibel-Palade bodies of the endothelium also
synthesize vWF.
 It is the combination of exposure of vWF, subendothelial collagen,
ATP, and inflammatory mediators which provide the gateway into
the second phase of primary hemostasis, known as platelet
adhesion.
 Mechanisms cont`d
ii. Platelet adhesion: is the process by which platelets attach to the
exposed subendothelial vWF.

 Post vascular damage, platelets begin to roll along vessel walls and
adhere to areas of exposed subendothelial collagen and vWF.

 Platelet membranes are rich in G protein (Gp) receptors located

within the phospholipid bilayer.

 Specifically, it is Gp Ib-IX receptor on platelets that bind to vWF

within the endothelium that creates the initial connection between
the two.

 Once bound, a variety of events can occur in the third phase of

primary hemostasis to activate the platelet.
 Mechanisms cont`d
iii. Platelet activation consists of platelets undergoing two
specific events once they have adhered to the exposed
vWF (i.e. the damaged vessel site). 
o First, platelets will undergo an irreversible change in
shape from smooth discs to multi-pseudopodal plugs,
which greatly increases their surface area.
o Second, platelets secrete their cytoplasmic granules.
 Platelet activation is mediated via thrombin by two
mechanisms.
o Thrombin directly activates platelets via proteolytic
cleavage by binding the protease-activated receptor.
o Thrombin also stimulates platelet granule release which
includes serotonin, platelet activating factor, and
Adenosine Diphosphate (ADP).
 Mechanisms cont`d
 ADP is an important physiological agonist which is stored specifically
in the dense granules of platelets.
 When ADP is released, it binds to P2Y1 and P2Y12 receptors on platelet
membranes.

 P2Y1 induces the pseudopod shape change and aids in platelet

aggregation.
 P2Y12 plays a major role in inducing the clotting cascade.
 When ADP binds to its receptors, it induces Gp IIb/IIIa complex
expression at the platelet membrane surface.
 The Gp IIb/IIIa complex is a calcium-dependent collagen receptor
which is necessary for platelet-to-endothelial adherence and platelet-
to-platelet aggregation.
 Simultaneously, platelets synthesize Thromboxane A2 (TXA2). TXA2
further intensifies vasoconstriction and platelet aggregation (next step
in the primary hemostasis process).
The process of platelet activation readies the local environment for
platelet aggregation.
 Mechanisms cont`d
iv. Platelet aggregation; begins once platelets have been
activated. 
 Once activated, the Gp IIb/IIIa receptors adhere to vWF
and fibrinogen.
 Fibrinogen is found in the circulation and forms a
connection between the Gp IIb/IIIa receptors of
platelets to interconnect them with each other.
 This ultimately forms the weak platelet plug.

Basically, primary hemostasis allows the culmination of a

weak platelet plug to temporarily protect from hemorrhage
until further stabilization of fibrinogen to fibrin via thrombin
occurs in secondary hemostasis.
 Mechanisms cont`d
B. Secondary Hemostasis; involves the clotting factors acting in a
cascade to ultimately stabilize the weak platelet plug.

This is accomplished by completing three tasks

(1)triggering activation of clotting factors
(2)conversion of prothrombin to thrombin, and
(3)conversion of fibrinogen to fibrin.  

These tasks are accomplished initially by 1 of 2 pathways; the

extrinsic and intrinsic pathway, which converge at the activation
of factor X and then complete their tasks via the common
pathway.
Calcium ions are required for the entire process of secondary
hemostasis.
 Clotting Factors
Thirteen clotting factors are identified:
Factor I →Fibrinogen
Factor II → Prothrombin
Factor III → Thromboplastin (Tissue factor)
Factor IV → Calcium
Factor V → Labile factor (Proaccelerin or accelerator globulin)
Factor VI → Presence has not been proved
Factor VII → Stable factor
Factor VIII → Antihemophilic factor (Antihemophilic globulin)
Factor IX → Christmas factor
Factor X → Stuart-Prower factor
Factor XI → Plasma thromboplastin antecedent
Factor XII → Hageman factor (Contact factor)
Factor XIII → Fibrin-stabilizing factor (Fibrinase).
 Mechanisms cont`d
i. The extrinsic pathway; includes tissue factor (TF) and
factor VII (FVII).

 It is initiated when TF binds to FVII, activating FVII to

factor VIIa (FVIIa), forming a TF-FVIIa complex.

 This complex, in turn, activates factor X (FX). Note, the

TF-FVIIa complex can also activate factor IX of the
intrinsic pathway, which is called the alternate pathway.

 Once Factor X is activated to FXa by TF-FVIIa complex,

the cascade continues down the common pathway.
 Mechanisms cont`d
ii. The intrinsic pathway; includes Hageman factor (FXII), factor XI
(FXI), factor IX (FIX), and factor VIII (FVIII).

 The process is initiated when FXII comes into contact

with exposed subendothelial collagen and becomes activated to
FXIIa.

 Subsequently, FXIIa activates FXI to FXIa, and FXIa activates FIX

to FIXa.

 FIXa works in combination with activated factor VIII (FVIIIa) to

activate factor X.

 Once Factor X is activated by FIXa-FVIIIa complex, the cascade

continues down the common pathway.
 Mechanisms cont`d
iii. The common pathway; is initiated via the activation of
Factor Xa.

 Factor Xa combines with Factor Va and calcium on

phospholipid surfaces to create a prothrombinase
complex ultimately activating prothrombin (aka Factor
II) into thrombin.

 This activation of thrombin occurs via serine protease

cleaving of prothrombin.

 Now, thrombin activates factor XIIIa (FXIIIa). FXIIIa

crosslinks with fibrin forming the stabilized clot.
Mechanisms cont`d
 Mechanisms cont`d

Stages of blood coagulation. a = Activated, + = Thrombin induces formation of more thrombin (positive feedback);
HMW = High molecular weight.
ANTICLOTTING MECHANISM IN THE BODY
Under physiological conditions, intravascular clotting does not occur. It is
because of the presence of some physicochemical factors in the body.
1. Physical Factors
i. Continuous circulation of blood.
ii. Smooth endothelial lining of the blood vessels.
2. Chemical Factors – Natural Anticoagulants
i. Presence of natural anticoagulant called heparin that is produced by the
liver
ii. Production of thrombomodulin by endothelium of the blood vessels
(except in brain capillaries).
Thrombomodulin is a thrombin-binding protein. It binds with thrombin and
forms a thrombomodulin-thrombin complex. This complex activates
protein C. Activated protein C along with its cofactor protein S inactivates
Factor V and Factor VIII.
Inactivation of these two clotting factors prevents clot formation
iii. All the clotting factors are in inactive state.
ANTICOAGULANTS
Substances which prevent or postpone coagulation of blood.
Anticoagulants are of three types:
1. Anticoagulants used to prevent blood clotting inside the body, i.e.
in vivo. E.g. Dicoumoral and warfarin
2. Anticoagulants used to prevent clotting of blood that is collected
from the body, i.e. in vitro. E.g. Oxalate (poisonous), Citrate (store
blood and for RBC & PLT counts- Dacie`s solution).
3. Anticoagulants used to prevent blood clotting both in vivo and in
vitro. Heparin, EDTA
PROCOAGULANTS (Hemostatic agents)
Substances which accelerate the process of blood coagulation. They
are: thrombin, snake venom, extracts of lungs and thymus
(thromboplastin), sodium or calcium alginate (hegman factor),
oxidized cellulose (hegman factor)
TESTS FOR BLOOD CLOTTING
Blood clotting tests are used to diagnose blood disorders. Some
tests are also used to monitor the patients treated with
anticoagulant drugs such as heparin and warfarin.

1. BLEEDING TIME; (BT) is the time interval from oozing of blood

after a cut or injury till arrest of bleeding. Usually, it is determined
by Duke method using blotting paper or filter paper method. Its
normal duration is 3 to 6 minutes. It is prolonged in purpura.

2. CLOTTING TIME; (CT) is the time interval from oozing of blood

after a cut or injury till the formation of clot. It is usually
determined by capillary tube method. Its normal duration is 3 to 8
minutes. It is prolonged in hemophilia.
TESTS FOR BLOOD CLOTTING
3. PROTHROMBIN TIME; (PT) is the time taken by blood to clot
after adding tissue thromboplastin to it. Blood is collected and
oxalated so that, the calcium is precipitated and prothrombin is not
converted into thrombin

Normal duration of prothrombin time is 10 to 12seconds. It is

prolonged in deficiency of prothrombin and other factors like
factors I, V, VII and X. However, it is normal in hemophilia.

Other are;
• Partial prothrombin time
• International normalized ratio
• Thrombin time.
 Pathophysiology

Thrombosis is the process of blood clot (thrombus) formation in a

blood vessel.

 Virchow triad is an important concept that highlights the primary

abnormalities in pathology that can lead to the clotting
mechanism proceeding to thrombosis.

 The triad is composed of stasis or turbulent blood flow,

endothelial injury, and hypercoagulability of the blood.

i. Abnormal (stasis) or turbulent blood flow can lead to thrombosis.

Normal blood flow is laminar. Turbulent blood flow leads to
endothelial injury thus promoting the formation of a thrombus.
 Pathophysiology cont`d

 An example of turbulent blood flow is in the aneurysm of

weakened vessels.
 Another aspect of abnormal blood flow, venous stasis, such as in
post-operative bed rest, long distance traveling in a car or plane,
or immobility due to obesity can lead to endothelial injury thus
promoting thrombosis.

ii. Endothelial Injury leads to platelet activation and the formation

of a thrombus.
 This may be a result of inflammation of the endothelial surface of
the vasculature.
 Hypercholesterolemia is an example of a chronic inflammatory
condition which progresses into endothelial injury.
 Pathophysiology cont`d

iii. Hypercoagulability (thrombophilia) is any disorder of the blood

that predisposes a person to thrombosis.

 This may be a result of inherited clotting disorders such as a

Factor V Leiden mutation or an acquired clotting disorder such as
disseminated intravascular coagulation.
 Pathophysiology cont`d
Hemorrhage occurs when blood escapes from its vessel (ruptured)
walls. Platelet dysfunction, or clotting factor dysfunction, can be further
broken down into which part of the clotting mechanism physiology is
affected.

 Disorders of Primary Hemostasis: vWF, Platelet defects, or Receptor

Interference
Von Willebrand Factor disease, Bernard-Soulier disease, Glanzmann
thrombasthenia, Medication-induced

 Disorders of Secondary Hemostasis: Clotting Factor Defects

Factor V Leiden, Vitamin K deficiency, Hemophilia, Anti-phospholipid
antibody syndrome, Disseminated intravascular coagulation, Liver
disease, Medication induced.

 Defects in Small Vessels; Trauma, Aneurysm rupture, Vasculitides