PT & aPTT

Manish Pandey

1
Hemostasis Is a Balance Between
Clot Formation & Clot Dissolution.

2
 Normal Hemostasis

Clot formation Clot dissolution

(Coagulation) (Fibrinolysis)

FDP
PT D-Dimer
aPTT vWF
Thrombin Time
HMWK
Fibrinogen
Prekallikrein
Individual factor tests
3
Thrombosis

Abnormal Hemostasis is Thrombosis

Formation of Blood Clot (thrombus) in

normal blood vessels

Thrombotic occlusion of a vessel after

relatively minor injury

4
Hemostasis involves the interaction of:

 Vascular Endothelium
 Platelets
 Coagulation Factors and
 Fibrinolytic Proteins

5
 Hemostasis has 2 main functions:
2. Induce a rapid & localized hemostatic
plug at the site of vascular injury
(clot formation)
3. Maintain Blood in a fluid, clot-free state
after the injury is healed
(clot dissolution)

6
7
Primary Hemostasis

Injury

Endothelial Cells

Exposure of thrombogenic surface

(subendothelial extracellular matrix)

8
 Platelets adhere and get activated

Change shape

Release secretory granules

(e.g. ADP, TXA2)

Attract other platelets and Aggregate

Hemostatic plug or Primary Platelet Plug 9

Secondary Hemostasis
Fibrin is required to stabilize the primary
platelet plug
Fibrin is formed by two coagulation
pathways i.e. Extrinsic & Intrinsic
Extrinsic Pathway is initiated when Tissue
Factor (III) present in damaged organ comes
in contact with Blood
Intrinsic Pathway is initiated when Factor
XII binds to a negatively charged “foreign”
surface exposed to Blood
10
Coagulation Factors
Factor Trivial Name Pathway
Prekallikrein Fletcher factor Intrinsic
HMWK Contact activation Intrinsic
cofactor
I Fibrinogen Both
II Prothrombin Both
III Tissue Factor Extrinsic
IV Calcium Both 11
V Proaccelerin, Labile Both
factor
VI (Va) Accelerin Both

VII Proconvertin Extrinsic

VIII Antihemophilic factor Intrinsic

A
XI Antihemophilic factor Intrinsic
B 12
XII Hageman Factor Intrinsic

XIII Fibrin Stabilizing factor Both

13
14
15
16
PT and aPTT testing

 PT (Prothrombin Time) test is done for

deficiency of factors of extrinsic pathway

 aPTT (activated Partial Thromboplastin

Time) test is done for deficiency of factors
of Intrinsic pathway

17
Effects of Hereditary or Acquired Factor
Deficiency on the PT & aPTT
aPTT prolonged, PT normal
 Deficiencies of intrinsic pathway Factor(s)
VIII, IX, XI or XII
PT prolonged, aPTT normal
 Deficiency of extrinsic Pathway factor VII
 Occasionally, mild to moderate deficiency
of common pathway factor(s) fibrinogen,
II, V or x
18
Both PT and aPTT Prolonged
 Deficiency of common pathway factor(s)
fibrinogen, II, V, or X
 Multiple factor deficiencies

19
 Mixing studies in PT
Treat specimen with heparinase (degrades heparin)

PT normal, prolongation due to heparin PT prolonged

PT mixing study (1:1 mix of patient and normal plasma

PT normalizes aPTT remains

PT initially prolonged
shortens and
then prolongs
Factor Deficiency;
Measure factors
Inhibitor (specific
I, II, V, VII, X Factor V factor inhibitor,
inhibitor rare)
(rare) 20
 Mixing studies in aPTT
Treat specimen with heparinase (degrades heparin)

aPTT normal, prolongation due to heparin aPTT prolonged

aPTT mixing study (1:1 mix of patient and normal plasma

aPTT normalizes aPTT remains

aPTT initially prolonged
shortens and
then prolongs
Factor Deficiency;
Measure factors
Inhibitor, most
VIII, IX, XI, XII Factor VIII commonly Lupus
inhibitor Anticoagulant 21
22
Fibrinolytic Mechanism
Stable Fibrin Clot

Activation of Protein C and Protein S

Secretion of t-PA by endothelial cells

Plasminogen Plasmin

Stabilized fibrin clot

X, Y fragments

Plasmin Degrades D-E-D fragments

E fragment + D dimer23
Fibrinolysis
 As soon as the injury is healed clot
dissolution starts, to restore the normal flow
of Blood
 Plasminogen is converted to the active form
Plasmin by 2 distinct Plasminogen
Activators (PAs):
 tissue plasminogen activator (t-PA) from
injured endothelial cells
 Urokinase from Kidney endothelial cells and
plasma
24
Fibrinolysis

 or Kallikrein from Intrinsic Pathway

 Plasminogen can also be activated by the
bacterial product (e.g. Streptokinase) –
having significance in certain Bacterial
Infections
 Free Plasmin is neutralized by α2- plasmin
inhibitor (PAI)
 t-PA activity is also blocked by PAI

25
 Endothelial cells modulate the coagulation
/ anticoagulation balance by releasing
PAIs
 PAIs block fibrinolysis by inhibiting t-PA
binding to fibrin as it is most active when
bound to fibrin

26
Fibrinolysis

Three types of Natural Anti-coagulants

regulate clotting:
2.antithrombin III – inhibit thrombin activity
and Factors IXa, Xa, XIa and XIIa
3.Protein C and Protein S – Vitamin K
dependent proteins, inactivate Factors Va
and VIIIa
4.Plasmin

27
Fibrin Degradation Products or FDP’s include:

 fragments X and Y – early splits and

 D and E – late splits
 D-Dimer is the smallest cross-linked FDP

28
 D-Dimer are specific FDP formed only by
Plasmin activity on fibrin clot and not on
intact fibrinogen

 Thus the presence of D-Dimer indicates

that fibrin has been formed and so is a
marker for an ongoing in vivo thrombotic
condition

29
Clinical Significance of Hemostasis

 Hemophilia A: Caused by the deficiency of

Factor VIII
 Hemophilia B: Caused by the deficiency of
Factor IX
 Vitamin K deficiency
 (PIVKA’s) Protein Induced Vitamin K
Antagonism can be used in thrombotic
conditions
 Vitamin K dependent factors are
II, V, IX, & X 30
Clinical Significance of Hemostasis

 Liver Dysfunction
 Fibrinogen and Factor XIII deficiency
 Factor XI and Contact Activation
 Antithrombin Deficiency leads to DVT and
PE
 von Willebrand Disease: Deficiency of von
Willebrand Factor

31
DIC
(Disseminated Intravascular Coagulation)
Massive Injury or Sepsis

Massive release of Tissue Factor III

Excessive Activation of Thrombin

Coagulation becomes systemic

32
High consumption of Platelets, coagulation
factors

Over production of fibrin clot

Fibrin clot “disseminates” or spreads

throughout the microcirculation

Obstructing the blood flow to capillaries,

smaller vessels

33
Lack of blood supply leads to tissue injury
(decreased oxygenation, organ infarction
& necrosis)

Once again release of Tissue Factor

Second time coagulation activation

More consumption of coagulation factors

and platelets

34
 Continuous thrombi formation

Production capacity of Bone Marrow and

Liver reaches its maximum level

Activation of fibrinolysis at first site

High consumption of Plasmin, antithrombin,

Protein C and Protein S

35
Generation of Thrombin & Plasmin at the
same time

Plasmin acts on Fibrin Clots and produces

FDPs and D-Dimer

FDPs interfere with platelet function and

impair fibrin clot formation

Further bleeding results

36
 Thus an initial thrombotic disorder gets
converted into a serious bleeding disorder
 Whenever there is a widespread activation
of Thrombin the chances are that it may
lead to DIC

37
Pharmacological Intervention

Most commonly patients are on OAC (oral

anti-coagulant) therapy:
 warfarin – over dose can lead to Vit. K
deficiency
 heparin
Fibrinolysis:
 Aspirin
 Streptokinase, urokinase injections
 t-PA injections
38
INR & ISI values

 All PT reagents are calibrated against

WHO IRP (International Reference
Preparation)
 International Normalisation Ratio is
intended to make comparison similar
irrespective of the type of PT reagent
used worldwide
 International Sensitivity Index is a
measure of the sensitivity of particular
PT reagent 39
 Insensitive PT reagents will give
prolonged results only when factor levels
are very low
 Sensitive PT reagent give prolonged
results even when there is a mild change
in factor level
 Insensitive PT reagents have higher ISI
values
 Sensitive PT reagents have ISI value as
close to 1.0 as possible
40
Calculation of PT results

INR = (Ratio)ISI
ISI
Patient PT Time (secs)
INR =
Mean Normal PT (MNPT)

MNPT = Mean PT Time of at least 20 known

normal samples

41
Thanks

 Please send your feedbacks to:

 Priyank Dubey
 Ph: 09999990845
 priyank.exp@gmail.com
 Application Specialist

42