Hemostasis

Nino Gulatava
 Hemostasis
Hemostasis, the process by which the body seals a ruptured blood
vessel and prevents further loss of blood. Although rupture of larger
vessels usually requires medical intervention, hemostasis is quite
effective in dealing with small, simple wounds. There are three steps
to the process: vascular spasm, the formation of a platelet plug, and
coagulation (blood clotting). Failure of any of these steps will result
in hemorrhage—excessive bleeding.
 Vascular Spasm

When a vessel is severed or punctured, or when the wall of a vessel is

damaged, vascular spasm occurs. In vascular spasm, the smooth muscle
in the walls of the vessel contracts dramatically. This smooth muscle has
both circular layers; larger vessels also have longitudinal layers. The
circular layers tend to constrict the flow of blood, whereas the
longitudinal layers, when present, draw the vessel back into the
surrounding tissue, often making it more difficult for a surgeon to
locate, clamp, and tie off a severed vessel. The vascular spasm response
is believed to be triggered by several chemicals called endothelins that
are released by vessel-lining cells and by pain receptors in response to
vessel injury. This phenomenon typically lasts for up to 30 minutes,
although it can last for hours.
Formation of the Platelet Plug

In the second step, platelets, which normally float free in the plasma, encounter the area of
vessel rupture with the exposed underlying connective tissue and collagenous fibers. The
platelets begin to clump together, become spiked and sticky, and bind to the exposed collagen
and endothelial lining. This process is assisted by a glycoprotein in the blood plasma called
von Willebrand factor, which helps stabilize the growing platelet plug. As platelets collect,
they simultaneously release chemicals from their granules into the plasma that further
contribute to hemostasis. Among the substances released by the platelets are:
• adenosine diphosphate (ADP), which helps additional platelets to adhere to the injury site,
reinforcing and expanding the platelet plug
• serotonin, which maintains vasoconstriction
• prostaglandins and phospholipids, which also maintain vasoconstriction and help to
activate further clotting chemicals, as discussed next
A platelet plug can temporarily seal a small opening in a blood vessel. Plug formation, in
essence, buys the body time while more sophisticated and durable repairs are being made. In
a similar manner, even modern naval warships still carry an assortment of wooden plugs to
temporarily repair small breaches in their hulls until permanent repairs can be made.
 Coagulation

Those more sophisticated and more durable repairs are collectively

called coagulation, the formation of a blood clot. The process is
sometimes characterized as a cascade, because one event prompts the
next as in a multi-level waterfall. The result is the production of a
gelatinous but robust clot made up of a mesh of fibrin—an insoluble
filamentous protein derived from fibrinogen, the plasma protein
introduced earlier—in which platelets and blood cells are trapped.
Clotting Factors Involved in Coagulation

In the coagulation cascade, chemicals called clotting factors (or coagulation

factors) prompt reactions that activate still more coagulation factors. The
process is complex, but is initiated along two basic pathways:
• The extrinsic pathway, which normally is triggered by trauma.
• The intrinsic pathway, which begins in the bloodstream and is triggered by
internal damage to the wall of the vessel.
Both of these merge into a third pathway, referred to as the common
pathway . All three pathways are dependent upon the 12 known clotting
factors, including Ca2+ and vitamin K . Clotting factors are secreted primarily
by the liver and the platelets. The liver requires the fat-soluble vitamin K to
produce many of them. Vitamin K (along with biotin and folate) is somewhat
unusual among vitamins in that it is not only consumed in the diet but is also
synthesized by bacteria residing in the large intestine. The calcium ion,
considered factor IV, is derived from the diet and from the breakdown of
bone. Some recent evidence indicates that activation of various clotting factors
occurs on specific receptor sites on the surfaces of platelets.
Summarizes the three steps of hemostasis

An injury to a blood
vessel initiates the
process of hemostasis.
Blood clotting involves
three steps. First,
vascular spasm
constricts the flow of
blood. Next, a platelet
plug forms to
temporarily seal small
openings in the vessel.
Coagulation then
enables the repair of
the vessel wall once the
leakage of blood has
stopped. (b) The
synthesis of fibrin in
blood clots involves
either an intrinsic
pathway or an extrinsic
pathway, both of which
lead to a common
pathway.
Clotting Factors
The 12 clotting factors are numbered I through XIII according to the
order of their discovery. Factor VI was once believed to be a distinct
clotting factor, but is now thought to be identical to factor V. Rather
than renumber the other factors, factor VI was allowed to remain as a
placeholder and also a reminder that knowledge changes over time.
Factor number Name Type of molecule Source Pathway(s)
Common; converted into
I Fibrinogen Plasma protein Liver
fibrin
Common; converted into
II Prothrombin Plasma protein Liver* (Vitamin K required)
thrombin
Tissue thromboplastin or
III Lipoprotein mixture Damaged cells and platelets Extrinsic
tissue factor

IV Calcium ions Inorganic ions in plasma Diet, platelets, bone matrix Entire process

V Proaccelerin Plasma protein Liver, platelets Extrinsic and intrinsic

VI Not used Not used Not used Not used

VII Proconvertin Plasma protein Liver * (Vitamin K required). Extrinsic
Intrinsic; deficiency results
VIII Antihemolytic factor A Plasma protein factor Platelets and endothelial cells
in hemophilia A
Antihemolytic factor B
Intrinsic; deficiency results
IX (plasma thromboplastin Plasma protein Liver* (Vitamin K required).
in hemophilia B
component)
Stuart–Prower factor
X Protein Liver* (Vitamin K required). Extrinsic and intrinsic
(thrombokinase)

Antihemolytic factor C
Intrinsic; deficiency results
XI (plasma thromboplastin Plasma protein Liver
in hemophilia C
antecedent)

Intrinsic; initiates clotting in

XII Hageman factor Plasma protein Liver
vitro also activates plasmin
Stabilizes fibrin; slows
XIII Fibrin-stabilizing factor Plasma protein Liver, platelets fibrinolysis
Tissue factor
Tissue factor is a lipoprotein produced by monocytes, endothelial
cells, smooth muscle cells, and fibroblasts. Certain tissues appear
especially rich in tissue factor ( e.g. brain, lung, placenta). The tissue
factor apoprotein has now been purified.
Tissue factor lacks proteolytic activity and functions as a cofactor for
VII and VIIa in the activation of X.
Coagulation cascade
Tissue
TF TF TF
TF TF TF TF TF TF TF TF TF TF
TF TF

The quicker responding and more direct extrinsic

pathway (also known as the tissue factor pathway)
begins when damage occurs to the surrounding
tissues, such as in a traumatic injury.

Blood

11
Coagulation cascade
TF TF TF
TF TF TF TF TF TF TF TF TF TF
TF TF

Upon contact with blood

plasma, the damaged
extravascular cells, which are
extrinsic to the bloodstream,
release factor III
(thromboplastin).

12
Coagulation cascade
TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF

VIIa

Sequentially, Ca2+ then

factor VII (proconvertin),
which is activated by factor
III, are added, forming an
enzyme complex.

13
Coagulation cascade

TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa

This enzyme
complex leads to
activation of factor
X (Stuart–Prower
X Xa factor), which
activates the
common pathway.
The events in the
II IIa extrinsic pathway
are completed in a
matter of seconds.

I Ia Fibrin
Fibrinogen

14
Extrinsic pathway
Intrinsic Pathway

The intrinsic pathway (also known as the contact activation pathway) is longer and
more complex. In this case, the factors involved are intrinsic to (present within) the
bloodstream. The pathway can be prompted by damage to the tissues, resulting
from internal factors such as arterial disease; however, it is most often initiated
when factor XII (Hageman factor) comes into contact with foreign materials, such
as when a blood sample is put into a glass test tube. Within the body, factor XII is
typically activated when it encounters negatively charged molecules, such as
inorganic polymers and phosphate produced earlier in the series of intrinsic
pathway reactions. Factor XII sets off a series of reactions that in turn activates
factor XI (antihemolytic factor C or plasma thromboplastin antecedent) then factor
IX (antihemolytic factor B or plasma thromboplasmin). In the meantime, chemicals
released by the platelets increase the rate of these activation reactions. Finally,
factor VIII (antihemolytic factor A) from the platelets and endothelial cells
combines with factor IX (antihemolytic factor B or plasma thromboplasmin) to
form an enzyme complex that activates factor X (Stuart–Prower factor or
thrombokinase), leading to the common pathway. The events in the intrinsic
pathway are completed in a few minutes.
Intrinsic Pathway

HMWK-
Fitzgerald or
Williams fact
 TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa

Common Pathway
Both the intrinsic and extrinsic pathwa
lead to the common pathway, in which
fibrin is produced to seal off the vessel.
Once factor X has been activated by eit
X Xa the intrinsic or extrinsic pathway, the
Va
V enzyme prothrombinase converts facto
the inactive enzyme prothrombin, into
active enzyme thrombin. (Note that if
enzyme thrombin were not normally in
II IIa inactive form, clots would form
spontaneously, a condition not consiste
with life.) Then, thrombin converts fac
the insoluble fibrinogen, into the solub
I Ia fibrin protein strands. Factor XIII then
stabilizes the fibrin clot.

18
Coagulation cascade
TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa VIIa
VIIa

X Xa
Va
V

II IIa

I Ia

19
Coagulation cascade
TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa

XI XIa

IX IXa
X Xa
Va
V

II IIa

I Ia

20
Coagulation cascade
TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa

XI XIa

IX IXa
X Xa
VIIIa Va
V
VIII

II IIa

I Ia

21
Coagulation cascade
TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa

XI XIa

IX IXa
X Xa
VIIIa Va
V
VIII

II IIa
XIII XIIIa

I Ia

22
Coagulation cascade
TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa
---
XII XIIa

XI XIa

IX IXa
X Xa
VIIIa Va
V
VIII

II IIa

I Ia

23
Regulation of Hemostasis
Obviously, limiting mechanisms must be concurrently operative to avoid progressive
clotting of the intravascular circulation and limit the clot to the immediate are of
damage. Numerous control system limit the extent of coagulation:
1. The inherent instability of activated factors, which tend to rapidly loss biologic
activity
2. The rapid dilution of the local high concentration of activated factors by blood
flow
3. The rapid clearance of activated factors and soluble fibrin monomer-fibrinogen-
complexes by the reticuloendothelial system
4. The presence of certain globulins ( AT III, heparin cofactor II, 2-macroglobulin)
in the plasma that inhibit or inactivate the serine protease clotting factors
5. The activation and subsequent clearance of the cofactors V and VIII by activated
protein C (PC) and plasmin
6. The activation of the fibrinolytic pathway during coagulation and the release of a
protease from leucocytes within the clot, which cause clot digestion.
Coagulation cascade
TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa
TM
XII XIIa aPC PS
PC

XI XIa

IX IXa
X Xa
VIIIa Va
V
VIII

II IIa

I Ia

25
Coagulation cascade
TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa
TM
XII XIIa aPC PS
PC

XI XIa

IX IXa
X Xa
VIIIa Va
V
VIII

II IIa

I Ia

26
Coagulation cascade

TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa
TM
XII XIIa aPC PS
PC
AT slowly
XI XIa binds and
inactivates
IX IXa thrombin
X Xa and factors
VIIIa Va Xa, IXa,XIa
V and XIIa
VIII

II IIa

AT
I Ia

27
Mechanism of heparin
TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa
TM
XII XIIa aPC PS
PC

XI XIa

IX IXa
X Xa
VIIIa Va
V
VIII

II IIa
Heparin
AT
I Ia

28
Mechanism of vitaminK antogonist

TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa
TM
XII XIIa aPC PS
PC

XI XIa

IX IXa
X Xa
VIIIa Va
V
VIII

II IIa

AT
I Ia

29
Direct thrombin inhibitor’s mechanism
TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa
TM
XII XIIa aPC PS
PC

XI XIa

IX IXa
X Xa
VIIIa Va
V
VIII

II IIa Dabigatran

AT
I Ia

30
Direct inhibitor’s of Ха factor
TF TF
TF TF TF TF TF TF TF TF TF
TF TF TF TF
VIIa
TM
XII XIIa aPC PS
PC

XI XIa

IX IXa
X Xa
VIIIa Va
V
VIII
Rivaxoban
II IIa Apixaban

AT
I Ia

31
Scheme of coagulation steps

Intrinsic Pathway:aPTT IExtrinsic Pathway: PT, INR

TF
VIIa
XII XIIa

XI XIa

IX IXa
X Xa
VIIIa Va
V
VIII

II IIa Stabile fibrin clot

XIII XIIIa

I Ia
Common Pathway:TT,
Fibronogen
32
Laboratory evaluation of coagulation
Screening test or basic coagulogramm:
• Prothrombin time by Quick method ( sec)
• Prothrombin activity by index(%)
• INR
• Activated Partial thromboplastin time (aPTT) ( sec)
• Fibrinogen assays ( g/L)
• Thrombin Time ( sec)
Coagulometers
Detection Method of coagulation parameters

The result depends on the

initial viscosity of the sample

Often requires the introduction

of a correction factor

Weak clot problem with low

fibrinogen or factor XIII

Under the action of an alternating magnetic field, the

steel ball is set in motion, the device analyzes the
amplitude of the ball's oscillations during coiling
There are no restrictions on the degree of
Viscosimeter or clot
hemolysis, icterus and chylosis of the
method sample (!!!)
Optical Method

Ability to view the reaction progress for each test - an additional free diagnostic tool for
samples with missing numerical results

Ability to perform clotting tests on samples with low fibrinogen or factor XIII deficiency
Optical Method
Difference between the method

• Manufacturers of various coagulometric systems choose how their

device will determine the time of clot formation.

• The absolute values of the results of clotting tests of clotting time

obtained when analyzing the same sample on different test systems
do not have to coincide.

• To compare the results of clotting tests obtained on different test

systems with each other, it is necessary to normalize or calibrate
 Type of tests
Clotting Chromogenic

•PT
•Anti thrombin III(ATIII)
•aPTT
•Protein C
•Fibrinogen
•anti Ха
•Thrombin Time
•Factors
•Protein C
Immunoturbidimetric
•Protein S D-Dimer
Free Protein S
vWF:Ag
vWF:Act
 Thrombosis Bleeding
• D-dimer
• PT (INR) • PT (%)

Express Diagnostic
• APTT • APTT
• AT • TT
• Аnti Ха • Claus fibrinogen
• Аnti IIа
• HIT

2.2.ACT
ACT Bleeding
Bleeding
monitoring
monitoring screening
screening

Bleeding
Bleeding
Thrombophilia 5.5.APS
APS
Routine DIagnostic

Thrombophilia 2ndlevel
level
2nd

• АТ • LA Факторы свертывания:
• PC DRVVT screen
• PS DRVVT confirm • VIII • II • XIII
• Factor V Leiden SCT screen • IX • V • vWF Ag
SCT confirm
• Homocystein • XI • VII • vWF Rco
• CL IgG/M
• (D-dimer) • XII • X
• β2GP-I IgG/M
PROTHROMBIN TIME (PT)

PROTHROMBIN TIME
Method: Clot based assay
The prothrombin time (PT) is used to detect abnormalities in the extrinsic
and common pathway of coagulation. Specifically, the PT is prolonged if
there is a decrease in factor II, V, VII, X and/or fibrinogen. The degree of
prolongation is dependent upon the severity of the deficiency and the
number of clotting proteins decreased. The PT is affected by elevated factor
II, V, VII and X resulting in shortening of the PT. Since each lot of
thromboplastin is slightly different, reference ranges need to be determined
for the specific lot used. The sensitivity of the thromboplastin to various
factor levels as a single factor deficiency or combined as multiple factor
deficiency is influenced by the international sensitivity index (ISI) value of
the thromboplastin. Our laboratory uses a thromboplastin with an ISI value
of less than 1.4. Direct thrombin inhibitors, such as argatroban and
lepirudin, will falsely prolong clotting times in this assay
PROTHROMBIN TIME (PT)

The blood cells are separated from the liquid part

of blood (plasma) by centrifugation. The PT test
is performed by adding the patient's plasma to
some source of Tissue Factor (e.g.: a protein,
thromboplastin, from homogenized brain tissue)
that converts prothrombin to thrombin. The
mixture is then kept in a warm water bath at
37°C for one to two minutes. Calcium chloride
(excess quantities of ionized calcium) is added to
the mixture in order to counteract the sodium
citrate and allow clotting to start. The test is
timed from the addition of the calcium chloride
until the plasma clots. This time is called the
Prothrombin Time.
PROTHROMBIN TIME (PT)
The prothrombin test specifically evaluates the presence of factors VII, V,
and X, prothrombin, and fibrinogen. A prothrombin time within the 11 -
15 second range (depends on the source of thromboplastin used) indicates
that the patient has normal amounts of the above clotting factors.
A prolonged prothrombin time indicates a deficiency in any of factors VII,
X, V, prothrombin, or fibrinogen. It may mean that the patient has a
vitamin K deficiency (vitamin K is a co-factor in the synthesis of
functional factors II (prothrombin), VII, IX and X) or a liver disease (the
liver is the site of synthesis of the plasma protein factors). The
prothrombin time of patients receiving a vitamin K-competing coumarin
drug such as warfarin (anticoagulation therapy used in deep venous
thrombophlebitis) will also be prolonged, usually in the range of one and
one half to two times the normal PT time.
Activated Partial Thromboplastin Time test
The activated partial thromboplastin time (aPTT) is
a test performed to investigate bleeding disorders
and to monitor patients taking an anticlotting drug
such as heparin which inhibits factors X and
thrombin, while activating anti-thrombin.
The aPTT test uses blood which is decalcified to
prevent clotting before the test begins. The plasma
is separated by centrifugation. (Ionized) Calcium
and activating substances are added to the plasma to
start the intrinsic pathway of the coagulation
cascade. The substances are: kaolin (hydrated
aluminum silicate) and cephalin. Kaolin serves to
activate the contact-dependent Factor XII, and
cephalin substitutes for platelet phospholipids. The
partial thromboplastin time is the time it takes for a
clot to form, measured in seconds. Normally, the
sample will clot in 35 seconds.
INR- International Normalized Ratio
The problems associated with PT or APTT for monitoring vitamin K
antagonists (VKA) and unfractionated heparin (UFH) relate mainly to the
varying responsiveness of test reagent to single and/or multiple factor
deficiencies and inhibitors. There is considerable variability in the PT
thromboplastin reagent to the coagulation defect caused by VKA. Therefore,
to allow PT results from different laboratories to be comparable, a calibration
system that compares PT results to a World Health Organization (WHO)
standard expressed as the international normalized ratio (INR) was developed.
However, the INR is only valid for patients stabilized on VKA. This means
that they are neither reliable nor reproducible for patients with prolonged PT
for other reasons, e.g. liver disease, disseminated intravascular coagulation and
congenital factor deficiency. The INR is accurate only for values within the
1.5–4.5 range as only patient samples with INRs within this range were used
for calibration. This means that INR values >4.5 may no longer observe the
linear relationship demonstrated for those with INRs of 1.5–4.5.
INR- International Normalized Ratio
The Prothrombin time (PT) test, standardized as the INR test is most often used
to check how well anticoagulant tablets such as warfarin and phenindione are
working. Anticoagulant tablets help prevent the formation of blood clots (they
do not "thin the blood" as is commonly thought). This is particularly important
in people with heart conditions such as atrial fibrillation, with artificial heart
valves and for people with blood clots. The effect of drugs such as warfarin can
be determined by the prolongation of the PT (measured in seconds), or increase
in the INR (a standardized ratio of the patient's PT versus a normal sample), and
the dose adjusted accordingly.
The test can also be used to diagnose a bleeding disorder; a doctor will compare
the PT with other clotting tests to indicate where in the clotting system a defect
might lie.
Lastly, when liver disorders becomes serious, the liver loses the ability to make
essential proteins including clotting factors. The PT is one of the more sensitive
tests to monitor this.
Activated Partial Thromboplastin Time test

aPTT measures the integrity of the intrinsic system (Factors XII, XI,
VIII, IX) and common clotting pathways.
Increased levels in a person with a bleeding disorder indicate a
clotting factor may be missing or defective. At this point, further
investigation is needed and warrants the use of sensitive assays for
specific coagulation factors. Liver disease decreases production of
factors, increasing the PTT.
HEPARIN ACTIVITY (UNFRACTIONATED AND LOW
MOLECULAR WEIGHT)
Method: Chromogenic, anti-Xa activity assay.
This assay is calibrated using a hybrid unfractionated and low molecular
weight heparin curve. Generally patients on unfractionated heparin
therapy are monitored with the aPTT. Conditions other than heparin
may be present that alter the APTT making the test ineffective as a
heparin-monitoring tool. The most common cause of interference is the
presence of a lupus anticoagulant. Lupus inhibitors do not interfere with
the heparin activity assay.
The aPTT cannot be used to monitor low molecular weight heparin
therapy. Low molecular weight heparin inhibits factor Xa more potently
than thrombin. The Heparin Activity assay is the assay of choice to
monitor patients on Low Molecular Weight Heparin.
LIMITATIONS OF PT AND APTT
• 1. Artefact due to sample collection or contamination, e.g. inadequate volume,
difficult or traumatic phlebotomy causing coagulation activation, prolonged storage,
and failure to adjust for high haematocrit causing an increase in citrate to plasma
volume and artefactual prolongation of PT and APTT.
• 2. Derivation of normal range whereby 2.5% of otherwise normal individuals are
considered to be outwith the upper limit of normal.
• 3. Insensitivity to clinically important bleeding disorders with normal PT and APTT
(e.g. mild von Willebrand disease or hemophilia A, FXIII deficiency and alpha2-
antiplasmin deficiency).
• 4. Detection of conditions not associated with bleeding e.g. the lupus anticoagulant
which can prolong both the PT and APTT, FXII deficiency which prolongs APTT.
• 5. The same blood sample tested in different laboratories can give variable results;
mainly due to differences in commercial reagents having different responsiveness to
coagulation factor deficiencies and inhibitors and to a lesser extent, the automated
instrument.
PT
Some substances you consume - various foods, alcohol and many
medications - can interfere with the PT test. Antibiotics and
painkillers can increase PT and INR. Oral contraceptives, hormone-
replacement therapy (HRT), and vitamin K - either in a multivitamin
or liquid nutrition supplement - can decrease PT and INR. Make sure
that your doctor knows all the drugs you are taking and any changes
in medication so that the PT results are interpreted correctly.
 FIBRINOGEN
Method: Clot based Clauss or Kinetic method.
Acquired abnormalities of fibrinogen can be quantitative or qualitative and may be
associated with a bleeding problem or with thrombosis.
Decreased quantities of fibrinogen are noted in liver disease, renal disease, ascites,
acute DIC and asparaginase therapy.
Acquired dysfunctional fibrinogen is observed in nephrotic syndrome and DIC.
Fibrinogen is an acute phase reactant protein. It is markedly increased in
inflammation and infection.
During pregnancy the fibrinogen level rises rapidly with a two to three fold
increase noted by the end of the third trimester.
An elevated fibrinogen is an indication that an acute phase response is occurring
that may lead to increased levels of factor VIII, von Willebrand factor and PAI-1.
Recent studies suggest that chronically increased fibrinogen levels are associated
with an increased risk of arterial thrombosis including stroke and myocardial
MIXING STUDY (APTT or PT)
Mixing studies are used to determine whether a prolonged PT or
APTT is due to a factor deficiency or an inhibitor.
Mixing studies are based on two principles: 1) the inhibitor is present
in excess, and if present, it will inhibit normal and patient plasma, and
2) that 50% of any factor is enough to yield a normal test result.
Correction into the normal range indicates a factor deficiency. Lack of
correction suggests the presence of an inhibitor. Heparin
contamination must be excluded.
Mixing studies cannot be performed when the PT or APTT is within 2
or 5 seconds of normal range, respectively.
THROMBIN TIME (TT):
The thrombin time (TT) screens for defects in the conversion of
fibrinogen to fibrin. This test is a useful screening test for abnormal
fibrin formation, including:
1) the diagnosis of hereditary fibrinogen deficiencies and
dysfibrinogenemia,
2) DIC,
3) liver disease and
4) fibrinolysis. The thrombin time is prolonged by abnormally high
fibrin degradation products, low amounts of heparin, thrombolytic
agents, and direct thrombin inhibitors.
Interpretation of PT and PTT in Patients with a Bleeding or Clotting Syndrome

PT RESULT PTT RESULT POSSIBLE CONDITIONS PRESENT

Liver disease, decreased vitamin K,

Prolonged Normal
decreased or defective factor VII

Decreased or defective factor VIII, IX, XI or

Normal Prolonged XII, von Willebrand disease, or lupus
anticoagulant present

Decreased or defective factor I, II, V or X,

Prolonged Prolonged liver disease ,disseminated intravascular
coagulation (DIC)

Decreased platelet function,

thrombocytopenia, factor XIII deficiency,
Normal Normal
mild deficiencies in other factors, mild form
of von Willebrand’s disease, weak collagen
FIBRINOGEN
Inherited abnormalities may be due to a lack of fibrinogen (afibrinogenemia,
autosomal recessive), deficiency of fibrinogen (hypofibrinogenemia, autosomal
dominant or recessive) or a dysfunctional fibrinogen molecule
(dysfibrinogenemia, autosomal dominant). All of the mentioned conditions are
rare.
Dysfunctional fibrinogens are the most common and may be asymptomatic or
associated with an increased risk of bleeding or thrombosis depending on the
specific defect. The prothrombin time has a slight to moderate prolongation;
the APTT has a normal to slight prolongation; the thrombin time is moderately
prolonged. On a 1:1 mix the thrombin time may show partial correction.
The diagnosis of a dysfunctional fibrinogen can be confirmed with an antigenic
fibrinogen or total clottable fibrinogen determination. Typically the kinetic
fibrinogen will be lower than the antigenic or total clottable method
fibrinogen. To specifically classify the type of dysfunctional fibrinogen it is
necessary to perform specific research assays to identify the abnormality in the
protein. Direct thrombin inhibitors, such as argatroban and lepirudin, will
falsely prolong clotting times and falsely decrease the fibrinogen concentration.
FIBRINOGEN ACTIVITY (FACTOR I)
• This test measures the concentration of functional fibrinogen and
can be used to evaluate 1) disseminated intravascular coagulation
(DIC), 2) liver disease, 3) monitor individuals undergoing
thrombotic therapy, and 4) diagnose inherited and acquired
coagulopathies (afibrinogenemia, hypofibrinogenemia, and
dysfibrinogenemia). Fibrinogen is an acute phase reactant and can
be increased in inflammatory states, pregnancy and malignancies.
High concentrations of heparin or fibrin degradation products can
result in abnormal results.
D-DIMER
Fibrinolysis is mediated by plasmin, which degrades fibrin clots into D-
dimers and fibrin degradation products (FDP). Plasmin can also
degrade intact fibrinogen, generating FDP that are detected in FDP
assays.
Elevated D-dimers may be seen in DIC, thromboembolism, systemic
fibrinolytic states and liver disease due to decreased clearance.
D-dimers can also be elevated postoperatively, with significant
bleeding, hemodialysis, eclampsia, sickle cell crisis and other
conditions. Cancer patients often have positive D-dimers and FDP,
usually representing low-grade, chronic DIC. Serial D-dimers may be
used to monitor resolution of a known thromboembolism.