INTRODUCTION TO HEMOSTASIS

Definition of Terms

 Hemostasis
 Coagulation
 Fibrinolysis

History

 2nd Century: Aristotle and Plato

 12th Century: Moses Maimonides
 1803: Schonlein
 1913: Lee and White
 1930s: Quick

General Hemostatic Components

1. Extravascular Component

2. Vascular Component

3. Intravascular Component
a. Platelets
b. Coagulation Factors
c. Fibrinolytic System

Coagulation Factors in Hemostasis

1. Extrinsic Pathway

2. Intrinsic Pathway

3. Common Pathway

COAGULATION FACTORS IN HEMOSTASIS

FACTOR PREFERRED/COMMON NAME PATHWAY
I
II
III
IV
V
VI
 VII
VIII
IX
X
XI
XII
XIII
HMWK
PK

Balance in Hemostasis

1. Hypo-coagulation
 Inherited or acquired
 Abnormal bleeding due to either poor clot formation OR increased fibrinolysis
2. Hyper-coagulation
 Acquired diseases
 Lack of activation of the fibrinolytic system

Phases of Hemostasis

 Vasoconstriction

 Platelet Activation

 Coagulation

 Fibrinolysis

Blood Vessel Bleeding and Breach-Sealing

Blood Vessel Bleeding Produced Breach-Sealing

Capillary None Direct Sealing
Venule Petechiae Fused Platelets
Arteriole Petechiae Fused Platelets
Vascular contraction, fused
Vein Ecchymosis platelets, hemostatic factors
activation
Great vascular contraction,
Artery Hemorrhage more fused platelets, greater
hemostatic factors activation
PRIMARY HEMOSTASIS (THE VASCULAR SYSTEM)

Major Types of Blood Vessels

1. Arteries

2. Veins

3. Capillaries

Blood vessel structure

1. Lumen

2. Glycocalyx

3. Tunica intima

4. Tunica media

5. Tunica adventitia

The Resting Endothelial Cell

1. Non-thrombogenic
2. Significant in supplying nutrients to subendothelial structures
3. Barricades macromolecules and particulate matter circulating in the bloodstream

Functions of the Endothelial Cell

Non-Thrombogenic

1. Platelet function
 Negatively charged surface
 PGI2 , nitric oxide, 13-HODE
2. Coagulation
 Heparin sulfate, thrombomodulin
3. Fibrinolysis
 tPA

Thrombogenic
 1. Platelet function
 Collagen exposure
 Endothelin, vWF, PAF
2. Coagulation
 Tissue factor
3. Fibrinolysis
 PAI-1

Blood Vessel and Endothelial Cell Response upon Injury

1. Vasoconstriction
 Initial response
 Regulated by serotonin and thromboxane A2, as well as endothelin-1
2. Platelet adhesion

3. Vasodilation
 Regulated by PGI2 and nitric oxide

PRIMARY HEMOSTASIS (THE PLATELETS)

Platelet Production

Thrombopoiesis

 Platelet maturation and development

 Maturation from megakaryoblast to metamegakaryocyte takes 5-7 days

Growth factors:

1. Thrombopoietin
2. Meg-CSF
*GM-CSF and IL-3
*IL-6 and IL-11

Platelet Maturation Series

1. Megakaryoblast
2. Promegakaryocyte/Basophilic megakaryocyte
3. Megakaryocyte/ Granular Megakaryocyte/ Immature Megakaryocyte
4. Metamegakaryocyte/ Mature Megakaryocyte
5. Platelets

Platelets/Thrombocytes

 Cytoplasmic fragments of the megakaryocytes released to bone marrow, eventually, to

peripheral blood
 Life Span: 2-9 days (some books: 8-12 days)
 Diameter: 1-4um; Volume: 8-10fl; Shape: Discoid
 Appears dense blue to purple in PBS
  Large platelet – macrothrombocyte
 Giant platelet – megathrombocyte
 Small platelet – microthrombocyte
 Stress platelets
 Reticulated platelets

Platelet structure: Peripheral Zone

Glycocalyx

 Smooth with pore-like indentations; negatively charged

 Absorbs albumin, fibrinogen, other plasma proteins through endocytosis
 Incorporated with glycoproteins (Ia, Ib, Ic, IIa, IIb, III, IV, V, VI) which acts as
receptors for platelet activation
 Provides surface for adhesion of some coagulation factors (I,V,VIII, X, XI, XII,
XIII)

Gp Ia/IIa Collagen Adhesion

Gp VI
Gp Ib/IX/V vWF Adhesion
Thrombin
Gp IIb/IIIa Fibrinogen Aggregation
vWF
PAR1 Thrombin Aggregation
PAR2
P2Y1 ADP Aggregation
P2Y12
P2X1

Plasma membrane

 Lipid bilayer: proteins and lipids (primarily phospholipids)

 oNeutral PL: Phosphatidylcholine and sphingomyelin
oAnionic PL: phosphatidylinositol, phosphatidylethanolamine, and
phosphatidylserine
 Supplies archidonic acid for the production of thromboxane A2

Platelet Structure: Structural Zone

Submembrane Area

 Separates organelles from the internal side of the platelet plasma membrane
 Contains organized systems of filaments obscured by the sol-gel zone

Sol-Gel Zone

 Stable gel that regulates the internal arrangement of organelles and the shape
of the platelet
 Communication of the organelles with the external surroundings
o Circumferential microtubules/ Tubulin
 Maintains platelet’s shape; release of Alpha granule contents
 Regulates platelet’s response to stimuli
o Microfilaments
 Contraction and pseudopod formation
 Actin, myosin, and actomyosin (thrombosthenin): causes the
change in shape upon activation

Platelet Structure: Organelle Zone

Mitochondria

 ATP synthesis

Glycogen Granules

 For platelet metabolism

Lysosomes

 Contains neutral proteases, acid hydrolase, and bactericidal enzymes

Microperoxisomes

 Contains lipids

Dense Bodies/ Granules (Delta Granules)

 2-7 per platelet; contents are released directly to plasma upon platelet activation

ADP Platelet aggregation

ATP Unknown function
Serotonin Vasoconstriction
Ca and Mg Platelet activation; Coagulation
 Alpha Granules

 50-80 per platelet; fuses with the SCCS upon platelet activation
 Selected platelet specific proteins:
Vascular fibroblasts and smooth
Platelet – derived growth factor
muscle growth
Thrombospondin Adhesion
Inhibits heparin; suppresses
Platelet Factor 4
megakaryocytopoiesis
Inhibits heparin; smooth muscle
Beta-thromboglobulin
growth
Factor V Coagulation

 Selected plasma proteins

Fibronectin Adhesion
Factors I,V, VIII, vWF, HMWK Coagulation
Protein C Control of coagulation
Plasminogen Fibrinolysis
A2-Antiplasmin Control of fibrinolysis
PAI-1
Albumin Unknown function

Platelet Factors

PF1 Adsorbed Factor V

PF2 Thromboplastin-like material/Fibrinogen-activating factor
PF3 Platelet thromboplastin/Phospholipid surface
PF4 Anti-Heparin factor
PF5 Fibrinogen coagulant factor
PF6 Anti-fibrinolytic factor
PF7 Platelet thromboplastin/Phospholipid Surface

Platelet Structure: Membrane Systems

Surface Connected Canalicular System

 Plasma membrane invades the interior of the platelet

 Twists sponge-like throughout the platelet, enabling it to store more of the hemostatic
proteins of the glycocalyx, increasing its surface area
 Allows for enhanced interaction of the platelet with its environment
 Routes for endocytosis and secretion of alpha granules

Dense Tubular System

 Parallel and closely aligned (but separate) from the SCCS

 Remnant of the rough ER
 Sequesters Ca and bears a series of enzymes that support platelet activation
o Phospholipase A2, cyclooxygenase, and thromboxane synthetase
o Phospholipase C
 Vascular Integrity

 Fill the “gaps” when endothelial cells separate during contraction or when the ECs are
sloughing off
 PDGF nurture endothelial cells

Platelet Function

Adhesion

 Sticking of platelets to any surface except other platelets

 Occurs in response to the exposure of subendothelial connective tissue which is
composed of adhesive molecules:
o Collagen, vWF, fibronectin, thrombospondin
 Glycoproteins that aids adhesion
o Gp Ib/IX/V
o Gp Ia/IIa
o Gp VI

Activation

 Morphologic and functional changes

o Discoid shape  Pseudopods = increased surface area
o Release/secretion of granules from alpha, dense and lysosomes
 Agonists (substances capable of activating platelets):
o Platelet-derived:
 ADP, serotonin, PAF, and thromboxane A2
o Non-platelet derived:
 Thrombin, collagen, epinephrine

Aggregation

 Sticking of platelets to other platelets

 Requires the activation of Gp IIb/IIIa
 Primary vs. secondary aggregation

Contact Activation

 Activation of Factor XII absorbed by the platelet due to the release of ADP
 Collagen-induced activation of platelets
 After secondary platelet aggregation, the phospholipid bilayer undergoes the “flip-flop”
rearrangement

Clot Retraction

 Platelets pull fibrin threads to strengthen the clot

 The glycogen in the platelets are provided for the enzymes required in contracting