Haemostasis

 What is Haemostasis
o Literally “Blood” “stopping” – following trauma to the blood vessels…
o A state of equilibrium between;
 Fibrinolytic factors Blood thinning
 Anticoagulant factors
 Coagulant factors
Blood thickening
 Platelets
o Why is this balance important?
 Coagulation
 Allows the stimulation of blood clotting processes during injury
where blood changes from its liquid state
 Thrombosis
 Limits the extent of the response to the area of injury to prevent
excessive or generalised blood clotting
 Fibrinolysis
 Starts the process that eventually leads to the breakdown of the
clot as part of healing
 Bleeding
o Loss of balance of Haemostasis
o This may be caused by;
 A reduction in platelet number/function (primary haemostasis)
 Reduction in platelet number
o Failure in platelet production
o Shortened platelet survival
o Increased splenic pooling
 Reduction in platelet function
o Anti-platelet drugs
o Inherited causes
 Reduction in coagulation factor(s) (secondary haemostasis)
 Congenital causes;
o Von Willebrand Disease
 Reduction in level/function of Von Willebrand
Factors
o Haemophilia A
o Haemophilia B
 Acquired causes;
o Liver disease
o Anticoagulants
o Disseminated intravascular coagulation (DIC)

Treatment à Replace clotting factor

 Increased Fibrinolysis
 Disseminated intravascular coagulation (DIC)
Treatment à Thrombolytic therapy
 Thrombosis
 o When there is a blood clot in intact blood vessel
o Contributing factors in Thrombosis;
 Blood à Dominant in venous thrombosis
 Vessel wall à Dominant in arterial thrombosis
 Blood flow à Complex both
o Types of thrombosis;
 Venous thrombosis
 Changes in blood that increase the risk of venous thrombosis;
o Reduced anticoagulant protein levels
 Usually genetic
o Increased clotting factors/platelets
 Eg.
 Pregnancy
 Myles proliferative disorder

Processes

 Formation of a blood clot at the site of injury, general;

o Injury
o Contraction of blood vessel
o Primary haemostasis – Formation of an unstable platelet plug at the site of the
injury
 Sufficient for small injuries, otherwise this falls apart
o Secondary haemostasis – Formation of a stable fibrin clot
 Binds and stabilizes the platelet plug
o Fibrinolysis
 Dissolution of clot and vessel repair
 Primary Haemostasis
o Injury to the vessel wall…
o ADHESION

 The collagen under the epithelial lining of the vessel is exposed due to
vascular damage
 The platelet binds to the collagen, either;
 Directly
o through GPIA receptor on platelet
 Through a Von Willebrand factor bound to the collagen
o through platelet glycoprotein (GP) Ibα
 Platelet is ACTIVATED – There is a conformational shape change in the
platelet. This leads to;
 Formation of Spicules
o Encourage platelet-platelet interaction
 Conformational shape change in GpIIb/IIIa to provide binding sites
for Fibrinogen receptor
 Release of granules
o Dense granules
o ADP
o α-granules
o Thromboxane A2
 Platelet aggregator
 Vasoconstrictor
o AGGREGATION

 Fibrinogen binds to GpIIb/IIIa receptor (along Ca2+)

 This leads to “outside-in” signalling – further activates platelets
 Epithelial cells regulate platelet binding and activation;
 Prostacyclin (PG12)
o Secreted by epithelial cells
o Vasodilator
o Supresses platelet activation
 Cyclooxygenase
o Secreted by epithelial cells
o Inhibits prostacyclin
 The active flow of blood also counterbalances the effect of platelet plug
formation
o What is a Platelet?
 Features;
 Discoid
 Non-nucleated
 Contains granules
 Significant cell surface receptors;
 Thromboxane A2 receptor
 P2Y12
o ADP receptor
o Binding on ADP causes activation of Gp IIb/IIIa
 Anti-platelet drugs;
 Asprin
o Reduces platelet aggregation by;
 Inhibits Thromboxane A2 production
 Irreversibly binds Cyclooxygenase
o Effects last for around 7 days, until most platelets have
turned over again.
 Clopidogrel
 o Irreversibly blocks ADP receptor p2Y12 on the platelet cell
membrane
 Therefore prevents Gp IIb/IIIa activation

o What is a Von Willebrand factor?

 Multimeric glycoprotein
 Synthesized by;
 Endothelial cells
 Megakaryotes
 Circulates in the blood plasma
 Mediates adhesion of platelets to the site of injury
 Promotes platelet-platelet aggregation
 Secondary haemostasis – formation of a stable fibrin clot
o Liver
 Synthesizes most clotting factors
 Apart from factor V – this is produced in megakaryocytes and VWF
 Vitamin K is vital in the synthesis of some factors
 Eg. Carboxylation of glutamic acid residues by vitamin K
o Process;
 Blood encounters Tissue factor
 Leads to initiation – production of
Prothrombin (Factor 2/Factor II)
 Factor 2 leads to the production of
Factor 2a/Thrombin
 Thrombin/Factor 2a binds to
Thrombomodulin on the
endothelium
 This leads to activation of
protein C
 Protein C (with Protein S) leads to;
 Inactivation of some factors (including Factor 2a/thrombin)
 o By binding to the thrombin-thrombomodulin complex
 Active clotting factors
 Inactive zymogen/proenzyme à active enzyme
o Through;
 Splitting of one or more peptide bonds
 Exposure of active sites
 Work on exposed phospholipid surface of platelets (with the help of
Ca2+)
 Helps;
o Localise reactions
o Accelerate reactions

o What is Tissue factor (TF)?

 Mainly located at sites which are not exposed to blood under normal
conditions
 Therefore blood only encounters Tissue factor at the site of vascular injury
o Tests of coagulation;
 Prothrombin time (PT)
 Measures integrity of extrinsic pathway
 Process;
o Blood is collected into a blue capped bottle containing
sodium citrate which chelates calcium
o The sample is spun to produce platelet-poor plasma
o TF, Phospholipids and Calcium are added
 This starts the reaction
 Recombinant thromboplastin is a source of both TF
and Phospholipids and is commonly used
o The length of time taken for the blood to clot is recorded
 PT may take longer;
o If certain factors are reduced in activity
o If Fibrinogen is reduced in activity
 INR – International normalised ratio
o This is a standard way of presenting coagulation time, taking
into account differences in the solutions added
 Activated Partial thromboplastin time (APTT)
 Measures integrity of intrinsic pathway
 Process;
o Contact aviator, phospholipid and calcium is added to
citrated plasma
o Time taken to clot is recorded
 APTT may take longer;
o A reduction in one or more clotting factors
o In conjunction with PROLONGED PT
 Multiple depetion/reduction in co-factors
o ISOLATED prolonged APTT
 Haemophilia A
 Haemophilia B
 Factor XI deficiency
 Factor XII deficiency
 Does not result in bleeding
 o Main anticoagulant drugs;
 Heparin
 Increases effect of Antithrombin
 Warfarin
 Vitamin K antagonist
 Oral
 Must be monitored by regular blood testing
 DOACs
 Directly inhibit either;
o Thrombin
o Factor Xa
 Orally available
 Do not usually require monitoring

 Fibrinolysis
o Process;
 Plasminogen à Plasmin
 With the help of t-PA (Tissue-Plasminogen activator)
 Plasmin binds to the Lysine on the fibrin Clot
 Leads to the formation of FIBRIN DEGRADATION PRODUCTS (FDP)
o What is Plasmin?
 Principle Fibrinolytic enzyme
 Can break down;
 Fibrin
  Other protein components of plasma (eg. Fibrinogen)
o Therefore NOT specific
 Circulates in inactive form – Plasminogen
 Activated by t-PA (Tissue-Plasminogen activator)
 Inhibited by antiplasmin
o What is Tissue-Plasminogen activator (T-Pa)?
 Thrombolytic agent
 Administered Intravenously to selected patients;
 Presenting with;
o Ischaemic stroke
 Blockage in artery in brain
 Time-dependent
 Must be given within an hour of symptom
onset
o Pulmonary emboli
 Blockage in one of the arteries in the lung
o Myocardial infarction
 Previously used on patients with myocardial
infarction
 Now has been largely replaced with stenting and
angioplasty
 High risk of bleeding with use
o Antifibrinolytic drugs
 Bind to the lysine binding site on Plasminogen, preventing its activation
(by preventing binding to fibrin)
 Used in
 Treating trauma
 Surgical patients
 Patients with bleeding disorders