Hemostatic

Introduction
• Normal hemostasis is best conceptualized according to its major
components-vessel wall, platelet function, coagulation factor cascade,
and clot inhibition/fibrinolysis.
• These components work together to prevent prolonged bleeding or
thrombosis under normal physiologic conditions.
• Disruption of the vascular endothelium is a potent stimulus to clot
formation.
• As a localized process, hemostasis by cellular and protein components
acts to seal the break in vascular continuity, limit blood loss, and begin
the process of wound healing.
 Primary Hemostasis
• Primary hemostasis refers to the role of blood vessels and
platelets in the initial formation of a platelet plug in response
to a vascular injury
• mechanisms are activated either by injuries to blood vessels or
by the common place desquamation of dying or damaged
endothelial cells
• the blood vessel contracts to seal the wound or reduce the
blood flow (vasoconstriction).
• Procoagulant substances are exposed or released by the
damaged endothelium.
 Primary Hemostasis
• Platelets are activated, adhere to exposed collagen, secrete the
contents of their granules, and aggregate with other platelets
to form a platelet plug

• Rapid, short-lived response

• Defects in the primary hemostasis system such as

thrombocytopenia, platelet disorders, or von Willebrand
disease can cause debilitating, sometimes fatal, chronic
hemorrhage.
 Secondary Hemostasis
• Secondary hemostasis is the activation of a series of plasma proteins in
the coagulation system to form a fibrin clot
• is triggered by tissue damage that exposes TF, a protein present in the
membrane of subendothelial cells—fibroblasts and smooth muscle
cells—but not on endothelial cells
• Delayed, long-term response
• plasma transports at least 16 glycoproteins, mostly trypsin like
enzymes called serine proteases.
• These proteins circulate as inactive zymogens that become activated
during the process of coagulation and, in turn, form complexes that
activate other zymogens to ultimately generate thrombin
 Components of the hemostatic
response
• The normal hemostatic response to vascular damage depends
on a closely linked interaction between the blood vessel wall,
circulating platelets and blood coagulation factors
• The five major components involved
• platelets
• coagulation factors
• coagulation inhibitors
• Fibrinolysis
• blood vessels
 Platelets structure
• Platelets are extremely small and discoid, 0.5-3.0 μm in
diameter, with a mean volume of 7 – 11 fL
• The glycoproteins of the surface coat are particularly important
in the platelet reactions of adhesion and aggregation
• Adhesion to collagen is facilitated by glycoprotein Ia (GPIa).
• Glycoproteins Ib (defective in Bernard – Soulier syndrome) and
IIb/IIIa (also called α IIb and β 3) (defective in Glanzmann ’ s
thrombasthenia) are important in the attachment of platelets
to von Willebrand factor(VWF) and hence to vascular
subendothelium
 Platelets tructure
• The platelet contains three types of storage granules: dense,
α and lysosomes .
• The more frequent specific α granules contain clotting
factors, VWF, platelet - derived growth factor (PDGF) and
other proteins.
• Dense granules are less common and contain adenosine
diphosphate (ADP), adenosine triphosphate (ATP), serotonin
and calcium.
• Lysosomes contain hydrolytic enzymes
 Platelet antigens
• Several platelet surface proteins have been found to be
important antigens in platelet
• Human platelet antigens (HPA) specific autoimmunity
• In most cases, two different alleles exist, termed a or b alleles
(e.g. HPA - 1a).
• Platelets also express ABO and human leucocyte antigen(HLA)
class I but not class II antigens
 Platelet function
• formation of mechanical plugs during the normal hemostatic
response to vascular injury
• Platelet function falls into three:
• adhesion
• aggregation
• release reactions and amplification
• The immobilization of platelets at the sites of vascular injury
requires specific platelet – vessel wall (adhesion) and platelet
– platelet (aggregation) interactions
 Platelet adhesion
• The binding of glycoprotein (GP) Ib (which consists of four
proteins: GPIb α , GPIb β , GPIX, GPV) leads to adhesion to the
subendothelium
• and also exposes the GPIIb/IIIa ( α IIb β 3 integrin) binding
sites to fibrinogen and von Willebrand factor leading to
platelet aggregation.
• The GPIa site permits direct adhesion to collagen and also
exploses the GPIIb/IIIa binding site
 Platelet aggregation
• This is characterized by cross - linking of platelets through
active GPIIb/IIIa receptors with fibrinogen bridges.
• A resting platelet has about 50 – 80 000 GPIIb/IIIa receptors,
which do not bind fibrinogen, VWF or other ligands.
• Stimulation of a platelet leads to an increase in GPIIb/IIIa
molecules, enabling platelet cross - linking with fibrinogen
bridges.
Platelet release reaction and amplification
• Primary activation by various agonists induces intracellular
signalling, leading to the release of α granule contents
• These have an important role in platelet aggregate formation
and stabilization
• The ADP released from dense granules has a major positive
feedback role in promoting platelet activation.
• Thromboxane A 2 (TXA2) is important in secondary
amplification of platelet activation to form a stable platelet
aggregate
 Thromboxane A 2 (TXA2)
• It is formed de novo upon activation of cytosolic phospholipase A 2
(PL A2)
• TXA2 is a labile substance and lowers platelet cyclic adenosine
monophosphate (cAMP) levels initiates the release reaction.
• TXA2 not only potentiates platelet aggregation, but also has
powerful vasoconstrictive activity
• The release reaction is inhibited by substances that increase the level
of platelet cAMP and production of prostacyclin (PGI 2 )
• High levels of cAMP lead to low free calcium ion concentrations and
prevent aggregation and adhesion
synthesis of prostacyclin and thromboxane A2
 Platelet procoagulant activity
• After platelet aggregation and release, the exposed membrane
phospholipid (platelet factor 3) is available for two reactions in
the coagulation cascade
• The first (tenase) involves activation of factors IXa, VIIIa and X
in the formation of factor Xa
• The second (prothrombinase) results in the formation of
thrombin from the interaction of factors Xa, Va and
prothrombin (II)
• Both phospholipid - mediated reactions are calcium -ion
dependent
 Natural inhibitors of platelet function
• Nitric oxide (NO) is constitutively released from endothelial
cells and also from macrophages and platelets
• It has a short half - life of 3 – 5 s.
• It inhibits platelet activation and promotes vasodilatation
• Prostacyclin synthesized by endothelial cells also inhibits
platelet function and causes vasodilatation by raising cyclic
guanosine monophosphate (GMP) levels
• An ectonucleotidase (CD39) acts as an ADPase and helps
prevent platelet aggregation in the intact vessel wall
 VASCULAR INTIMA IN
HEMOSTASIS
• Intimal cells and their environment play a premier role in
hemostasis.
• The innermost lining of blood vessels is a monolayer of
metabolically active endothelial cells
• An elastin-rich internal elastic lamina and its surrounding layer
of connective tissues support the endothelial cells.
• In all blood vessels, fibroblasts occupy the connective tissue
layer and produce collagen.
• Smooth muscle cells in arteries and arterioles, but not in the
walls of veins, venules, or capillaries, contract during primary
 Procoagulant Properties of Damaged Vascular
Intima
• vascular intima promotes coagulation
• vasoconstriction in arteries and arterioles
• rich in collagen, a flexible, elastic structural protein that binds and
activates platelets
• endothelial cells secrete VWF
• secrete P-selectin, an adhesion molecule that promotes platelet and
leukocyte binding
• secrete immunoglobulin-like
• adhesion molecules called intercellular adhesion molecules (ICAMs)
and platelet endothelial cell adhesion molecules (PECAMs) that
promote leukocyte binding
Anticoagulant Properties of Intact Vascular
Intima
• providing a smooth inner surface that evens the blood flow and
prevents harmful turbulence
• form a physical barrier between blood and the substances in the
basement membrane that activate clotting, such as collagen
• Endothelial cells synthesize and secrete a variety of substances that
maintain normal blood flow e.g Prostacyclin, a platelet inhibitor
• Nitric oxide is synthesized in endothelial cells, vascular smooth
muscle cells, neutrophils, and macrophages
• Secretion of tissue factor pathway inhibitor (TFPI)
• Secretion of Thrombomodulin and heparan sulfate
 Fibrinolytic Properties of Vascular
Intimacells support fibrinolysis with the secretion of Tissue
• Endothelial
plasminogen activator (TPA)
• During thrombus formation, both TPA and plasminogen bind to
polymerized fibrin
• TPA activates fibrinolysis by converting plasminogen to plasmin, which
slowly digests fibrin and restores blood flow
• Endothelial cells, as well as other cells, may secrete plasminogen
activator inhibitor 1 (PAI-1), a TPA control protein that inhibits
fibrinolysis
• Thrombin bound to thrombomodulin activates thrombin-activatable
fibrinolysis inhibitor(TAFI), which increases the tendency for thrombus
formation