BLOOD COAGULATION

Key Points

Liver-derived coagulation factors circulate in an inactive state and are activated in a cascading
fashion, leading to thrombin-mediated fibrin formation
Thrombosis is triggered in most cases by vessel wall damage and exposure of blood to tissue factor,
collagen, and von Willebrand factor (VWF)
Tissue factor leads to factor VIIa-mediated activation of the coagulation cascade
Exposure of blood to subendothelial collagen and VWF leads to platelet activation
Activated platelets provide a phospholipid-rich surface for activation of factors IX and X
Thrombin converts fibrinogen to fibrin and plasminogen to plasmin
The mature clot is composed of a meshwork of platelets and fibrin
Plasmin induces clot dissolution by cleaving fibrin into fibrin degradation products
Coagulation factors II, VII, IX, and X require vitamin K-mediated gamma-glutamyl carboxylation for
activity
The anticoagulant effect of coumarin drugs (vitamin K reductase inhibitors) results from reduced
synthesis of functional vitamin K-dependent factors
The anticoagulant effect of heparin results from enhancement of antithrombin III-mediated inhibition
of factor Xa and thrombin
Von Willebrand disease, the most common inherited bleeding disorder, results from deficiency
(quantitative or qualitative) of von Willebrand factor (VWF)
Hemophilia A and B are X-linked bleeding disorders caused by deficiency of factors VIII and IX,
respectively
DIC is an acquired bleeding disorder often triggered by sepsis that results from consumption of
platelets and coagulation factors by systemic intravascular microthrombosis
Hereditary thrombophilia is a group of thrombotic disorders caused by mutations in a variety of
coagulation factors, the most common being factor V, that lead to recurrent venous and arterial
thrombosis.

Key Words and Concepts

Acquired hemophilia A
Activated partial thromboplastin time (aPTT)
Activated protein C resistance
ADAMTS13
Agarose gel protein electrophoresis
Antiphospholipid antibody
Antiphospholipid syndrome
Antithrombin III (ATIII)
ATIII deficiency
Buffy coat
Coumarin skin necrosis
D dimer
DDAVP
Dilute Russell viper venom test
Disseminated intravascular coagulation (DIC)
Dysfibrinogenemia
Ecchymosis
Epistaxis
Euglobulin clot lysis test
Extrinsic pathway
Factor V Leiden
Factor VII
Factor XII (Hageman factor)
Factor XIII deficiency
Factor XIIIa
Fibrin
Fibrin degradation products (FDP)
Fibrinolysis
HELLP syndrome
Hemophilia A
Hemophilia B
Heparan sulfate
Heparin
Heparin resistance
Heparin-induced thrombocytopenia
High-molecular-weight kininogen (HMWK)
Hyperhomocysteinemia
Hypofibrinogenemia
Intrinsic pathway
Liver disease
Low-molecular-weight heparin
Menorrhagia
Mixing study
Neonatal purpura fulminans
Petechiae
Plasmin
Platelet adhesion
Platelet aggregation

Prekallikrein
Primary fibrinogenolysis
Protein C deficiency
Protein S deficiency
Proteins induced from vitamin K antagonism or absence (PIVKA)
Prothrombin time (PT)
Prothrombinase complex
Pseudo-VWD
Reptilase time
Ristocetin cofactor activity
Ristocetin-induced platelet aggregation (RIPA)
Serine proteases
Tenase complex
Thrombin
Thrombin time
Thrombomodulin
Thrombophilia
Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS)
Tissue factor
Tissue factor pathway inhibitor
Tissue plasminogen activator (t-PA)
Type 1 VWD
Type 2A VWD
Type 2B VWD
Type 2N VWD
Type 3 VWD
Unfractionated heparin
Urea clot lysis assay
Urea clot solubility assay
Urokinase (u-PA)
Vitamin K deficiency
Vitamin K-dependent factors
von Willebrand disease (VWD)
VWF
VWF-cleaving enzyme (ADAMTS13)
Warfarin
Zymogens

Blood is a slightly viscous fluid suspension composed of approximately equal volumes of plasma and
cells. If anticoagulated blood in a tube is spun at low speed in a centrifuge, the erythrocytes collect in a
layer at the bottom of the tube, and the leukocytes and platelets form a pale layer known as the buffy
coat on top of the erythrocyte layer, leaving a layer of cell-free plasma above. Under normal
circumstances blood is a fluid suspension that freely circulates through myriad blood vessels
throughout the body. However, breaches in or damage to the blood vessel wall initiates a process
designed to minimize blood loss, known as blood coagulation, or thrombosis. The result of blood
coagulation is formation of a semisolid clot composed of fibrin and platelets that acts as a sealant at
the site of the blood vessel breach or injury. In the process, platelet-derived growth factor (PDGF)
released by clotted platelets stimulate vascular repair. Vascular repair is followed by dissolution of the
clot by plasmin-mediated fibrinolysis.
The classic coagulation factors are designated by Roman numerals I-XIII. In their active form, factors
are referred to by the numeral followed by the letter a, as in factor Va. Some factors are referred to
more often by their common names than by their Roman numerals, such as fibrinogen (factor I),
prothrombin (factor II), tissue factor (factor III), calcium (factor IV). Factor VI is now known as factor
Va. The coagulation factors can be functionally classified, with many falling into one of three groups:
the zymogens, the cofactors, and the regulators (table 1).
Table 1. Functional Classification of Coagulation Factors
GROUP

FACTORS

Zymogens

II (prothrombin), VII, IX, X, XI, XII

Cofactors

III (tissue factor), V, VIII, HMWK, prekallikrein

Regulators

ATIII, protein C(S), thrombomodulin

Transglutamase

XIII

Other essential factors I (fibrinogen), IV (calcium), phospholipid

(platelets)

Most coagulation factors are zymogens, proteins synthesized by hepatocytes that circulate in plasma
as inactive precursors. Following limited proteolytic cleavage, zymogens are converted to serine
proteases (so named for the serine-binding site located within the proteolytic domain) that activate
other coagulation zymogens. Two key coagulation reactions take place on the phospholipid-rich cell
surface of platelets and endothelial cells with the help of anchoring cofactors V and VIII, both of which
are produced by endothelial cells. Following thrombin-mediated activation, factors Va and VIIIa
stabilize the tenase complex (IXa-VIIIa complex) and prothrombinase complex (Xa-Va complex)
on the surface of activated platelets and endothelial cells. The platelet proaggregatory factor VWF
does not directly contribute to the coagulation cascade; instead, it indirectly contributes by binding to
and stabilizing factor VIII. VWF, unlike the other factors, is secreted by endothelial cells and
megakaryocytes as high molecular weight multimers and quickly converted into smaller multimers by
the circulating metalloproteinase ADAMTS13.

Blood Coagulation
The coagulation process begins with vessel wall injury, leading to tissue factor expression by
activated endothelial cells and adhesion of platelets to subendothelial collagen and VWF (Figures 1
and 2). Circulating factor VII binds to tissue factor and is converted to factor VIIa to form the tissue
factor-VIIa complex. Free tissue factor-VIIa complexes are rapidly inactivated in blood by tissue
factor pathway inhibitor, whereas complexes that bind to endothelial cell and platelet membranes
trigger calcium- and phospholipid-dependent surface activation of factors IX and X with help from
cofactors VIII and V, respectively. A small amount of factor X is converted to factor Xa on the
endothelial cell surface by the tissue factor-VIIa complex, and a small amount of factor V is converted
to factor Va by factor Xa, cellular proteases, or both. Factor Va binds to tissue factor-bearing cell
membranes and recruits factor Xa to form the stable, membrane-bound Xa-Va prothrombinase
complex. Cell-bound factor Xa converts prothrombin to thrombin 300,000 times faster than free factor
Xa, because free factor Xa is rapidly inactivated in plasma by tissue factor pathway inhibitor. The XaVa prothrombinase complex formed on the endothelial cell surface converts a small amount of
prothrombin (factor II) to thrombin that, although insufficient for fibrin clot formation, converts factors
VIII and IX to VIIIa and IXa, respectively. Unlike factor Xa, free factor IXa is not inactivated by plasma
tissue factor pathway inhibitor and can diffuse and bind to activated platelets to form the factor IXaVIIIa (tenase) complex that enhances the conversion of factor X to Xa, generating a large amount of
Xa-Va prothrombinase complex on the surface of activated platelets and yielding enough thrombin to
form a fibrin clot. The thrombotic process is further enhanced by thrombin-mediated conversion of
factor XI to XIa, thereby further boosting factor IXa production. Thrombin, a highly potent serine
protease, rapidly converts plasma fibrinogen to fibrin monomer and factor XIII to factor XIIIa, a
transglutamase that covalently cross-links fibrin monomer to yield stable fibrin polymer. When bound
to thrombomodulin on the surface of endothelial cells, thrombin also activates protein C, which, in
concert with protein S, inactivates factors Va and VIIIa. Factor Va and VIIIa inactivation prevents
generation of factor Xa and thrombin by the tenase and prothrombinase complexes, respectively.
Thrombin also plays a role in conversion of plasminogen into plasmin and thus contributes not only to
clot formation but to clot dissolution as well. Thrombin plays a central role in coagulation not only by
proteolytic activation of fibrinogen; factors V, VIII, XI, and XIII; plasmin; and protein C but also by
activation of platelets (Figure-3).

Figure 1. Coagulation cascade

Figure 2. Endothelial cells and platelets in coagulation activation

Figure 3. Thrombin, which plays a central role in coagulation.

Much of the excess thrombin generated at the site of vascular injury is rapidly inactivated by
antithrombin III (ATIII). ATIII inactivates thrombin by binding irreversibly in a 1:1 complex. This
binding reaction is enhanced several thousandfold by the closely related sulfated
mucopolysaccharides heparan sulfate and heparin. Heparan sulfate is expressed on the luminal
surface of vascular endothelium, whereas endogenous heparin is produced by mast cells and
basophils. Following thrombin binding to ATIII, heparan sulfate and heparin are released from the
complex, again making them available for binding to free ATIII. The thrombogenic action of thrombin is
also controlled by binding of free thrombin to thrombomodulin, a membrane protein expressed by
endothelial cells. Thrombomodulin-bound thrombin activates protein C, which, when complexed with
protein S, inhibits clotting by inactivating coagulation cofactors VIIIa and Va.
Although the preceding model of tissue factor-initiated activation, known as the extrinsic pathway, is
the predominant pathway operative in the in vivo setting, a second activation pathway known as the
intrinsic pathway exists. In this pathway, coagulation is initiated by negative-charged surface
activation of plasma factor XII (Hageman factor) in the presence of plasma protein cofactors
prekallikrein and high-molecular-weight kininogen (HMWK). This pathway was discovered during
investigations of the in vitro phenomenon of spontaneous (intrinsic) clot formation in uncoated,
negatively charged glass tubes. Although factor XIIa can contribute to clotting via activation of the
zymogen factor XI, the role of the intrinsic pathway in initiation of the clotting cascade in vivo appears
to be minimal, because deficiencies of factor XII, prekallikrein, and HMWK are not associated with
increased bleeding. In contrast, factor XI deficiency is associated with bleeding; indicating that
thrombin-mediated (rather than factor XIIa-mediated) activation of factor XI is critical for normal
hemostasis.

Fibrinolysis
The combination of platelet adhesion, fibrin formation, and platelet aggregation at the site of
endothelial injury leads to formation of the stable fibrin-platelet clot. Dissolution of the fibrin clot is
initiated by the fibrinolytic enzyme plasmin, formed by proteolytic cleavage of the plasma precursor
plasminogen by thrombin and tissue plasminogen activator (t-PA), released by damaged
endothelial cells. The proteolytic byproducts of fibrinolysis, low-molecular-weight fibrinopeptide
fragments known collectively as fibrin degradation products (FDP), including D dimer, interfere with
thrombin-mediated fibrin formation by competitive inhibition.