Background and Physiology of Coagulation
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1 Objectives Background and Physiology of Coagulation Sarah M. Westberg, Pharm.D., BCPS Understand the physiology of how a thrombosis is formed and dissolved within the body Describe the role of platelets in forming a thrombosis Describe the role of the coagulation cascade in forming a thrombosis Be able to describe the natural processes by which clots are dissolved Hemostatic Balance Platelet Functions Adhesion Secretion Aggregation Fusion Platelet Structure Platelet Adhesion When subendothelial connective tissues are exposed in the blood, platelet adhere to that exposed tissue Subendothelial microfibrils bind to VWF, which then binds to GPIb binding site on the platelet
2 Platelet Adhesion Platelet Activation After adhesion, platelets will change shape, extrude long pseudopods which enhance platelet interaction Activated platelets adhere to exposed collagen by GPIb and vwf. Platelet Aggregation Platelet Secretion Aggregation begins immediately, prompted by presence of fibrinogen binding to GPIIb/IIIa complex Fibrinogen bridges form between adjacent platelets Once exposed to collagen or thrombin, platelets will secrete some of their granule contents (AFP, serotonin, fibrinogen, calcium) Activate prostaglandin synthesis, leading to production of thromboxane A2 (TXA2). Thromboxane A2 potentiates platelet aggregation and causes vasoconstriction Platelet/ Endothelial Cell ENDOTHELIAL CELL Phospholipid Phospholipase Arachidonic acid Cyclooxygenase 2 Endoperoxides Prostacyclin synthase Prostacyclin PLATELET Phospholipid Phospholipase Arachidonic acid Cyclooxygenase 1 Endoperoxides Thromboxane synthase Thromboxane A2 ATP - Adenylate cyclase + camp Phosphodiasterase AMP Lowers Calcium Platelet Aggregation Once ADP and thromboxane A2 are released (during secretion), more platelets aggregate ADP causes platelets to swell, adjacent platelet adhere to each other Liberates more ADP and thromboxane A2, therefore causing positive feedback Eventually build a platelet mass
3 Platelet Fusion Platelet Procoagulant Activity Irreversible platelet aggregation Thrombin encourages fusion Fibrin reinforces stability High concentrations of ADP, other enzymes released during secretion and platelet contractile proteins contribute to fusion The exposed phospholipid membrane on the activated platelet leads to : Formation of factor Xa (through IXa, VIIIa, and X) Formation of thrombin [from Xa, Va and prothrombin (II)] Role of coagulation cascade A biological amplification system which ends in the generation of thrombin Thrombin converts fibrinogen into fibrin. Fibrin enmeshes the platelets and converts unstable platelet plugs to firm stable hemostatic plugs Common Pathway Intrinsic Pathway Endothelial injury XII XI Ca ++ IX X VIII + Ca ++ XIIa XIa IXa II (prothrombin) Inhibitors Fibrinogen Warfarin Unfractionated Heparin Protein C Va + Ca ++ Ca ++ Fibrin Xa Stable Fibrin Clot Extrinsic Pathway Tissue Damage VII VIIa IIa(thrombin) XIIIa Ca ++ /tissue factor Antithrombin III (ATIII) Ca ++ XIII Coagulation Cascade Intrinsic Pathway Extrinsic/Tissue Factor Pathway Coagulation Cascade
4 Lipid Membrane Fibrin When fibrinogen is hydrolyzed by thrombin, fibrin monomers are formed These link to form a loose, insoluble fibrin polymer Factor XIII is activated by thrombin and calcium, and helps stabilize the fibrin polymers with covalent bond cross links Platelet-Fibrin Clot Natural limitations of coagulation Tissue factor pathway inhibitor (tfpi) accumulates at site of injury Inhibits Xa and VIIa and tissue factor Antithrombin inactivates serine proteases by forming high molecular weight stable complexes Protein C and Protein S Protein C is activated when thrombin binds to endothelial cell surface receptor thrombomodulin. Protein C destroys factors Va and VIIIa Protein S is a co-factor which facilitates binding of activated protein C to the platelet surface. Natural limitations of coagulation Fibrinolysis Fibrinolysis Plasminogen is converted to plasmin primarily by tissue plasminogen activator (tpa) tpa is released from the endothelial cells tpa binds to fibrin, and converts plasminogen in the thrombus to plasmin Protein C protects tpa by destroying inhibitors of tpa Plasmin digests fibrinogen, fibrin, factors V and VIII and others
5 Role of Endothelial Cells Hemostatic Process #1 Work to synthesize PGI2 and nitric oxide, which cause vasodilation and inhibit platelet aggregation Release tpa and activate fibrinolysis Synthesizes: Tissue factor & it s inhibitor (TFPI) Prostacyclin VWF Plasminogen activator Antithrombin and thrombomodulin Hemostatic Process #2 Hemostatic Process #3 Hemostatic Process #4 Hemostatic Process #5
6 Vessel Injury Collagen Exposure Vasoconstriction Platelet Adhesion and Release Reaction Thromboxane A2, ADP Platelet phospholipid Tissue Factor Reduced blood flow Platelet Aggregation Primary Hemostatic Plug Platelet fusion Stable haemostatic plug Blood coagulation cascade Thrombin Fibrin
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