Components of the

Haemostatic Response
Hiroshani Kulatunga
Objectives
• What is Haemostasis?

• Components of Haemostasis
The blood vessel
Platelets
Blood Coagulation
Inhibitors of Coagulation
The Fibrinolytic System
 Haemostasis
Arrest of bleeding

Functions of Hemostatic Mechanisms,

1. To maintain blood in fluid state while it remains

circulating within the vascular system
2. To arrest bleeding at the site of injury or blood loss
by formation of a haemostatic plug
3. To limit the process to the vicinity of the damage
4. To ensure the eventual removal of the plug when
healing is complete
Components in Haemostasis

Blood
Coagulation Co
a
ets Factors Inh gula
t el ibi tion
Pla tor
s

Fib syste
Ve od
l

rin m
sse
Blo

oly
tic
1. Blood vessel
• Endothelial cells forms a continuous monolayer
lining all blood vessels.

• In resting stage,
• non-thrombogenic
• supply nutrients to subendothelial structures
• act as a barrier to cells, macromolecules and
particulate matter circulating in the blood
stream

Activated/injured endothelium is prothrombotic

Vasodialators
Endothelial cells produce upon appropriate
stimulation.
1. Nitric Oxide- Maintains vascular relaxation and
inhibits platelet activation

2. Prostacyclin/ vasoconstrictors
Eg: Endothelin, thromboxane
Enhances vascular relaxation and inhibits platelet
adhesion and activation
Endothelial Anticoagulant activity
• Prostacyclin
inhibits platelet aggregation
• Nitric oxide
inhibits platelet aggregation
•Thrombomodulin
Binds thrombin to initiate protein C
activation
• Heparan sulfate proteoglycans
Bind and concentrate antithrombin on
endothelial surfaces
• Tissue Plasminogen activators
Activates fibrinolysis
• Tissue Factor Pathway Inhibitor
Inhibits the Tissue Factor/Factor VIIa complex
Endothelial procoagulant activity
• Tissue Factor
Released following endothelial injury

• Von Willebrand Factor

Forms bridges for platelet adhesion and
Aggregation

• Plasminogen Activator Inhibitor-1

Inhibits fibrinolysis
 Endothelium in haemostasis
Damaged endothelium has predominately proclotting
properties

– Release of Tissue Factor from activated endothelium and

subendothelial tissues

– Exposure of underlying collagen and other

subendothelial components provide sites for
platelet adhesion
02. Platlets
• Produced in the BM by fragmentation of cytoplasm
of Megakaryocytes

• Regulated by …………………………hormone

• Each megakaryocyte gives rise to 1000-5000

platelets

• Lifespan of a platelet - ??
 Platelet structure
• Extremely small, discoidal shape membrane bound
cells

• Diameter- 3.0x0.5µm

• Mean volume - 7-11fL

Glycoprotein receptors are present on the surface
coat.

Important in the platelet reactions of adhesion and

aggregation

There are 03 receptors on platelet surface.

Glycoprotien Ia (GPIa) -
Facilitate the adhesion to collagen

Glycoprotein Ib (GP Ib) -

Important in the attachment of platelets to VWF
hence to vascular endothelium

Glycoprotein IIb/ IIIa -

Important in the attachment of platelets to VWF
hence to vascular endothelium
Act as a receptor for fibrinogen (plt-plt
aggregations)
Canalicular system
open membrane formed by the invagination of
plasma membrane into the platelet interior.

This provides a large reactive surface area to

selectively absorb coagulation proteins.

Membrane phospholipids helps to convert,

factor X Xa
Factor II factor IIa
(prothrombin) (thrombin)
Storage granules

Dense - Less common

Contain ADP, ATP, serotonin and calcium

α - more frequent
contains clotting factors, VWF, platelet derived growth
factor(PDGF) and other proteins

Lysosomes - contain hydrolytic enzymes

Contents of the granules release into open canalicular system

during release reaction
 Aggregation of platelets
• Aggregation of platelets forms a temporary
haemostatic plug – bleeding arrested

• Later strengthened by deposition of fibrin (blood

clotting)
 Prostaglandin metabolism
Membrane Phospholipid
Phospholipase
Arachidonic acid
Cyclo oxygenase
PGG2, PGH2
Thromboxane A2 Prostacyclin
(platelets)++ -- (endothelium)
Aggregation
03. Blood Coagulation
• This involves a biological amplification system.
• Few initiating substances sequentially activate by
proteolysis and generate thrombin which converts
soluble fibrinogen to fibrin.
• Fibrin enmeshes the platelet aggregates at the sites
of vascular injury and converts the unstable primary
platelet plug to a stable , firm definitive haemostatic
plug.
• Vascular injury and platelet aggregation are the
major stimuli of coagulation
 Blood clotting Factors
Factor Factor
• I - fibrinogen • VIII - anti haemophilic globulin
• II - prothrombin • IX - Christmas factor
• III - tissue • X - Stuart - Prower factor
thromboplastin • XI - plasma thromboplastin
• IV - calcium • XII - contact factor (Hageman
• V - labile factor factor, glass factor)
• VII -stable factor • XIII - fibrin stabilizing factor
• HMW-K - High molecular weight kininogen
• Pre-K - Pre Kallikrein
• Ka - Kallikrein
• PL - Phospholipids
• Factor VIII needs vWF for its stability
 Coagulation Factors

Enzyme Precursors Co-Factors

II, VII,
IX,X,XI,XII,XIII I,III,V,VII,HMWK,C
and prekallekrin a2+, Phospholipids
Enzymatic Factors
• Circulate in inactive form
• Serine proteases except factor XIII
• Synthesized in Hepatocytes

Vitamin K dependent Factors

• Factor II
• Factor VII
• Factor IX
• Factor X
 Co-Factors
• Non-enzymatic participants that are necessary for
enzymatic coagulation reactions
 Prekallikren

kallikren
Extrinsic Pathway
• Extrinsic system is the one that gets activated in-vivo
(rapid, explosive response)

• Extrinsic system is activated when tissue thromboplastin

(TPL or tissue factor) is released which activates factor VII

• Also activate factor IX and X which leads to the

production of thrombin.

• Ca++ is important
 Intrinsic Pathway
Intrinsic system is activated when Factor XII (contact
factor) is activated. (contact with a wettable surface)

Intrinsic system is the one that gets activated in-vitro

(may play a role in major sites of trauma or surgery)

This is initiated secondarily to extrinsic pathway and

common pathway and it is continued to produce
thrombin by activating factor X
 Common Pathway
Common pathway initiates from activated factor X

Activated factor X convert

ProthrombinThrombin

Thrombin convert,
Fibrinogen Fibrin monomer
Fibrin multimer
XIIIa

Cross-linked fibrin
Fibrinolytic System
Fibrinolytic pathway Cont…
• Deposition and removal of fibrin is regulated by
fibrinolytic system

• Complex and multicomponent pathway with

activators and inhibitors.
But, centers around,
Fibrin
plasmin (fibrin cleaving enzyme)
•Plasmin - circulates in it’s inactive form
“plasminogen”

•Plasminogen - proenzyme in blood and tissue fluid

•Activated contact group coagulation factors( Factor

XIIa/HMWK/Kallikrein) cleave plasminogen to

plasmin

• Tissue plasminogen activator (T-PA) produced by

activated endothelium binds to plasminogen-fibrin
complex to activate plasminogen
 Coagulation Inhibitors
• Mechanism to ensure that the clot production is
limited to the site of injury and do not propagate
indefinitely.

Tissue factor pathway inhibitor (TFPI)

Antithrombin (Antithrombin III)
Protein C
Protein S
1. TFPI - rapidly quench the factor VIIa -TF complex

This is done by combining with factor Xa

Further propagation depend on the initially generated thrombin

(sufficient to activate intrinsic pathway)

2. Antithrombin - Physiological inactivator of thrombin
Binds with factor IIa and form inactive thrombin
antithrombin complex

This complex is cleared from the circulation by liver

This process is enhanced by the presence of heparin or

vessel wall heparin

Responsible to inactivate mare than 60% of heparin

Also inactivate factors X, IX, XI and XII (less degree)

• As thrombin moves away from the area of damage
it is also bound by thrombomodulin on the surface
of endothelial cells

Now it has changed from a procoagulant protein to

an anticoagulant one
• 3. Protein C - present to thrombin-thrombomodulin
complex by endothelial protein C receptor

When activated by thrombin cleavage acts to limit and

to arrest coagulation by inactivating factors Va and VIIIa

4. Above action is further enhanced by the action of

protein C’s cofactor – Protein S

Pc is subsequently inactivated by it’s own specific

inhibitor.