Secondary Hemostasis Part 1

Maam Gutierrez
Hemostasis
- maintaining the blood in a clot free/fluid state inside a vascular
compartment
- process by which the body stops bleeding

Secondary HS. When fibrin gets deposited at the injury site together
with the platelets, it makes the platelet plug more stable.
The Clotting/Coagulation Factors
- most are inherited: autosomal recessive
- almost all of them are glycoproteins so expect them to be
manufactured in the Liver.
In liver disorder, it is not impossible for the patient to bleed.

- process by which the body maintaining the blood circulating

in fluid form.

Exceptions:

- localized in the site of injury

- Calcium: CF4, not a protein but an ion.

- prevents excessive bleeding, prevents excessive clot formation.

Fibrinoloysis

- Tissue Thromboplastin/Tissue Factor: CF3, need not be synthesized

and activated. Found in cells/tissues all over the body.

- gradual process of clot dissolution; slower than coagulation

Primary Hemostasis

- Platelet Co-factor: CF8, circulates in the plasma in a form of a complex

because it is very small and will need a carrier protein: vWF. They circulate
together as a complex.

- interaction of blood vessels and platelets as a response to blood vessel

injury.
Blood vessels are lined with a single layer of endothelial cells
that supposedly do not attract platelets, clotting factors and anything
that stimulates coagulation cascade and also contain substances that
repel these.
Upon vascular injury, the exposure of collagen makes things
different. The endothelial lining will attract platelets leading to its
adhesion, deformity, granule release and aggregation. Chemicals will also
get attracted to the injury site leading to various reactions with the
endothelial cells.
Secondary Hemostasis

a. Factor 8C synthesized in the liver

b. Factor 8vWF found in the endothelial cells and in the alpha
granules of the platelet
- some CF are initially found in the plasma in inactive forms. When
activated, can be enzymes or cofactors.
The Nomenclature (refer to Hema2 manual)
FACTOR I

Fibrinogen

FACTOR II

Prothrombin

FACTOR III

Tissue Thromboplastin

- starts with Fibrin formation

Primary HS focuses on interaction of platelets and blood
vessels only and involves platelet plug formation which is reversible
until Fibrin stabilizes the plug. Fibrin formation marks the beginning of

FACTOR IV

Calcium

- mediators of inflammation
vWF
- not in itself a clotting factor, only a cofactor.

FACTOR V

Labile Factor/Proaccelerin

- functions primarily in platelet function: adhesion vWF

Stable Factor/Proconvertin/
Serum Prothrombin Conversion
Accelerator (SPCA)

Deficiency: most common inherited

FACTOR VII

Antihemophilic Factor A/

Hemophilia A and B: x-linked. Mostly affects male.

Platelet Cofactor1 (labile also)

Clotting factors may be grouped based on their Hemostatic Functions and

Physical Properties

FACTOR VIII

FACTOR IX

- autosomal recessive

Plasma Thromboplastin/
Christmas Factor/
Antihemophilic Factor B

FACTOR X

Stuart Prower Factor

FACTOR XI

Antihemophilic Factor C
Hageman Factor/Contact

FACTOR XII
Factor/Glass Factor
Laki-lorand Factor/

Based on Physical Properties: (refer to Hema2 Manual)

Contact Group Surface Bound called as such because this
group is involved in the contact phase of the intrinsic coagulation
system.
A. Factor 11
B. Factor 12
C. Prekallikrein
D. High Mol. Wt. Kinninogen
The contact group is essential in means of collagen exposure.
These clotting factors need to come in contact with collagen.(Contact
Phase)

FACTOR XIII
Fibrin Stabilizing Factor
PREKALLIKREIN

Fletcher Factor

HIGH MOL. WT.

Fitzgerald Factor/Contact

KINNINOGEN
Kinins

activation Factor/Williams/Flaujeac

Prothrombin Group Phospholipid Bound called as such

because they have an additional action; they form complexes on
the surface of phospholipids. Vit. K dependent; deficiency of
Vit.
K will lead to bleeding.
A. Factor 2
B. Factor 7
C. Factor 9
D. Factor 10

Complex formation is supported/facilitated by Vit. K through

Gamma Carboxylation Process
These clotting factors are also absorbed by Barium Sulfate or
Aluminum Hydroxide.
Barium Sulfate/Aluminum Hydroxide Absorption
- may be used to detect missing clotting factors
- addition of Barium Sulfate or Aluminum Hydroxide.
- Factors 2, 7, 9, 10 will precipitate
- centrifuge, separate plasma.
- plasma separated will be the plasma which is deficient
of factors 2, 7, 9, 10.
- FACTORS 2, 7, 9, 10 ARE ALL ABSORBED BY
BARIUM SULFATE OR ALUMINUM HYDROXIDE
Mixing Studies
- tests performed on blood plasma used to
distinguish factor deficiencies
Newborns are injected with vit. K to avoid bleeding since their
livers are not mature yet.
Fibrinogen Group Thrombin Sensitive group; readily affected by
thrombin or High Molecular weight group; includes large clotting
factors
A. Factor 1 most abundant
(200-400mg/dL)
B. Factor 5
C. Factor 8 Complex largest
D. Factor 13
(Factors 1, 2, 5, 8, 13) All these clotting factors are consumed
in the coagulation process. In a serum, do not expect Fibrinogen group
clotting factors because they will all be used up together with Factor 2.
Factor 8 Complex (CF 8 + vWF)

- involved in Hemophilia A and vWF DSE

o Factor 8C Low mol. Wt.; in
coagulation
o vWF High mol. Wt.; carrier protein portion
Factor 8C Antigen detects 8C
Factor 8R Antigen detects vWF o Factor
VIIIR:Rco Factor 8 Related
Ristocetin Cofactor Activity
Ristocetin used in Platelet Aggregometry; phased
out antibiotic due to increased risk of stroke.
Ristocetin induced platelet aggregation requires: vWF +
gp1aB95 receptor
Based on Hemostatic function:
As a Substrate all substances at one point are used as
substrates. Some substrates when activated become Enzymes,
the others become Cofactors.
A. Fibrinogen last/ultimate substrate; when
fibrinogen is converted to fibrin, coagulation
cascade ends. (1 HS)
As a Cofactor substrates that when activated, do not elicit
enzymatic activity. Instead, they bind to other clotting factors.
A. Factor 3/Tissue Factor
B. Factor 5
C. Factor 8
D. HMWK
As an Enzyme all other clotting factors not mentioned.
(except CF4/Calcium, because it is not included in the
nomenclature)
Transaminase
A. Factor 13/Fibrin Stabilizing Factor
Serine Protease
A. Factor 2
B. Factor 7
C. Factor 9
D. Factor 10
E. Factor 11

F.

Factor 12 (Fragments when activated

becomes Factor 12F)
G. PK
The Coagulation Process
- there are alternate linking pathways; there are different series
of events in vivo. Cascade theory is more on in vitro studies.
Classic Theory
- supports coagulation studies

In in vitro studies, Extrinsic Pathway is not readily initiated

unless there is addition of tissue thromboplastin.
In Cell based theory, Tissue factor is a receptor; binding site.
In Cascade theory, Tissue factor is Tissue Juice; secreted.
Tissue factor is believed to be a crude mixture of thromboplastin
and phospholipid. Lipoprotein by nature and the vital part is the
phospholipid portion.

- Paul Morawitz

TF = (thromboplastin + phospholipid)

- based on 2 events only:

- Release of TF triggers activation of Factor 7, and becomes

Factor 7a. As said before, Vit. K dependent factors form complexes, since
Factor 7 is one of them, it will form a complex which is Calcium aided.

Prothrombin is converted into thrombin by

enzyme thrombokinase
Fibrinogen is converted to fibrin
Cascade Theory
- Ratnoff, Davies and MacFarland
- Cascade effect, waterfall, domino, gisingan
- observed in vitro
Substrate activated -- enzyme activity -- next substance is used as
substrate by this enzyme -- activated and produces enzyme activity -- next
substance is used as substrate by second enzyme . . . (Cascade Theory)
Extrinsic Pathway
Intrinsic Pathway
Common Pathway Int. and Ext. merging
All are stimulated by Vascular Injury.
Extrinsic Pathway
- initiated by the release of Tissue Factor (CF3). This factor is not
originally found in the vascular compartment. There should be an injury
first to release tissue factor.

Extrinsic Tenase Complex

[TF+CF7a+Calcium] = CF10 Activation
- substrate is Factor 10 from the Common Pathway
Common Pathway starts with the activation of CF10, after the
Extrinsic Tenase Complex activates its substrate (CF10), the Extrinsic
Pathway ends.

Intrinsic Pathway
- called intrinsic because all that is needed in this pathway is
already present, not like the tissue factor which is released only after a
vascular injury. All factors are initially found inside the vascular
compartment.
- initiated by Collagen Exposure. Collagen has a negatively
charged surface that through contact activates Factor 12, becomes
Factor 12a. (Contact Phase)
Collagen + CF12 -- CF12a
CF12a combines with HMWK and leads to 2 different events.

1. CF12a + HMWK = CF11 to CF11a

Kallikrein and HWMK involves the complement system.
- CF11a activates factor 9 to CF9a. Since it is a Vit. K dependent
factor it leads to the formation of a complex composed of Calcium and
cofactor CF8a (CF8 was activated initially by Thrombin). Phospholipid (PF3)
from platelets will be stimulated and further goes to the activation CF10
from common pathway and merging extrinsic pathway.
Intrinsic Tenase Complex
[CF9a+CF8a+Calcium+PF3] = CF10 Activation
2. CF12a + HMWK = Prekallikrein to Kallikrein
Conversion of prekallikrein to serine protease, Kallikrein
leads to 2 different events also.
1. Kallikrein + HMWK = accelerates of CF12 conversion.
2. Kallikrein + CF12a = forms plasminogen activator.
Kallikrein and CF12a Complex converts plasminogen to
plasmin therefore, initiates fibrinolysis
An assumption made before about the intrinsic pathway is that,
when one of the clotting factors (CF12 and HWMK) is deficient, it will lead
to bleeding/prolonged BT since the clotting process will be interrupted
but in another instance, it was seen that deficiency of the said clotting
factors didnt lead to the patient bleeding, rather, the deficiency
increased thrombotic tendencies.
In vitro : CF12 and HMWK deficiency = bleeding
In vivo : CF12 and HMWK deficiency = clotting
CF11 deficiency = bleeding (Hemophilia C)
Common Pathway
- called Common pathway because it is where the intrinsic and
extrinsic pathways merge.

- starts by the activation of CF10 to CF10a with complex

formation.
Prothrombinase Complex
[CF10a+Calcium+CF5a+PF3] = CF2
- substrate is Prothrombin or CF2 which is further converted to
thrombin.