MECHANISM OF BLOOD

CLOTTING

SARTHAK MISRA
ROLL NO. 53
Date:12-03-2016

Coagulation
Coagulation is a complex process by which
blood forms clots.

Coagulation begins almost instantly after

an injury to the blood vessel has damaged
the endothelium (lining of the vessel).

Hemostasis

Primary hemostasis: platelets immediately

form a plug at the site of injury

Secondary hemostasis: occurs

simultaneously:
1. proteins in the blood plasma (clotting factors)
respond in a complex cascade
2. to form fibrin strands
3. which strengthen the platelet plug

Primary hemostasis . 1
Platelet activation
1. Damage to blood vessel walls exposes
sub endothelium proteins, most notably
collagen, present under the endothelium.
2. Circulating platelets bind collagen with
surface collagen-specific glycoprotein
Ia/IIa receptors.

3. The adhesion is strengthened by

circulating proteins (vWF)
Binding
intermediaries

vWF

von Willebrand factor

BLOOD

PLATELETS
ENDOTHELIAL CELL

vWF
vWF

vWF

EXPOSED
COLLAGEN
Gihan Gawish.Dr

4. This adhesion activates the platelets.

5. Activated platelets release the contents of stored
granules into the blood:
1.
2.
3.
4.
5.
6.

plasma ADP,
serotonin,
platelet activating factor (PAF),
von Willebrand factor (vWF) ,
platelet factor 4
thromboxane A2 (TXA2)

6. The granules' contents activate:

Gq-linked protein receptor cascade
Increased calcium concentration in the platelets' cytosol.
Activates protein kinase C
Activates phospholipase A2 (PLA2).

Modifies the integrin membrane glycoprotein

Increasing its affinity to bind fibrinogen.

7. The activated platelets changed shape from

spherical to stellate
8. The fibrinogen cross-links with glycoprotein
aid in aggregation of adjacent platelets.

Secondary hemostasis. 2
The coagulation cascade

The coagulation cascade of secondary

hemostasis has two pathways:

1. The contact activation pathway (formerly known as

the intrinsic pathway)
2. The tissue factor pathway (formerly known as the
extrinsic pathway)

That lead to fibrin formation.

The Clotting Cascade

Thrombin

Fibrin
polymers

Fibrin
monomers

Fibrinogen

Electron Micrograph of Fibrin

The biology of the coagulation

factors
The coagulation factors are generally serine proteases (
enzymes).
There are some exceptions. For example, FVIII and FV
are glycoproteins
Factor XIII is a transglutaminase.
Serine proteases act by cleaving other proteins at specific
sites.
The coagulation factors circulate as inactive zymogens.

The pathways are a series of

reactions
zymogen + its glycoprotein co-factor are
activated to become active components that
then catalyze the next reaction in the
cascade, ultimately resulting in cross-linked
fibrin.
zymogen is inactive enzyme precursor of a
serine protease

 Coagulation factors are generally indicated

by Roman numerals, with a lowercase a
appended to indicate an active form.

Generation of Thrombin
The prothrombin (Factor II) gene is located
on the eleventh chromosome (11p11-q12 (
Thrombin is produced by the enzymatic
cleavage of two sites on prothrombin by
activated Factor X (Xa).
The activity of factor Xa is greatly
enhanced by binding to activated Factor V
(Va), termed the prothrombinase complex.

 Prothrombin is produced in the liver and is

post-translationally modified in a vitamin Kdependent reaction that converts ten
glutamic acids on prothrombin to
gamma-carboxyglutamic acid (Gla).
In the presence of calcium, the Gla residues
promote the binding of thrombin to
phospholipid bilayers

 Deficiency of vitamin K or administration of

the anticoagulant warfarin inhibits the
production of gamma-carboxyglutamic acid
residues, slowing the activation of the
coagulation cascade.
In human beings the level of prothrombin in
the blood stream increases after birth and
typically peaks on the 8th day after which
the prothrombin level lowers to normal
levels

Action of Thrombin
Thrombin converts fibrinogen to an active form
that assembles into fibrin.
Thrombin also activates factor XI, factor V, and
factor VIII. This positive feedback accelerates the
production of thrombin.
Factor XIII is also activated by thrombin. Factor
XIIIa is a transglutaminase that catalyzes the
formation of covalent bonds between lysine and
glutamine residues in fibrin. The covalent bonds
increase the stability of the fibrin clot.

Action of Thrombin In platelets

In addition to the thrombin activity in the
coagulation cascades, thrombin also
promotes platelet activation, via activation of
protease-activated receptors on the platelet.

Ca

Gihan Gawish.Dr

Gihan Gawish.Dr

 A fibrin clot is formed by the interplay of the

intrinsic, extrinsic, and final common
pathways.
The intrinsic pathway begins with the
activation of factor XII (Hageman factor) by
contact with abnormal surfaces produced by
injury.

 The extrinsic pathway is triggered by trauma,

which activates factor VII and releases a
lipoprotein, called tissue factor, from blood
vessels. Inactive forms of clotting factors are
shown in red; their activated counterparts
(indicated by the subscript "a") are in yellow.
Stimulatory proteins that are not themselves
enzymes are shown in blue.
A striking feature of this process is that the
activated form of one clotting factor catalyzes the
activation of the next factor. I.

Cofactors
Various substances are required for the
proper functioning of the coagulation
cascade:
1. Calcium and phospholipids (a platelet
membrane constituent)
They are required for the tenase and
prothrombinase complexes to function.

 Calcium mediates the

binding of the complexes
via the terminal gammacarboxyl residues on
1. FXa
2. FIXa
(to the phospholipids
surfaces expressed by
platelets)
Prothrombin binds calcium ions with the modified
amino acid g-carboxyglutamate (red).

The CalciumBinding Region

of Prothrombin

Vitamin K-Dependent Clotting

Factors
Vitamin K

VII
IX
X
II

Synthesis of
Functional
Coagulation
Factors

Warfarin
Reduces the post-translational carboxylation of glutamate residues of factors II, VII, IX, X

Warfarin Mechanism of Action

Vitamin K

Antagonism
of
Vitamin K

VII
IX
X
II

Warfarin

Synthesis of
Non Functional
Coagulation
Factors

Warfarin-induced Skin Necrosis

The Clotting Process Must Be

Precisely Regulated
There is a fine line between hemorrhage and
thrombosis. Clots must form rapidly yet
remain confined to the area of injury.
Activated factors are short-lived because
they are diluted by blood flow, removed by
the liver, and degraded by proteases.
For example, the stimulatory proteins factors
Va and VIIIa are digested by protein C

 Protein C is a protease that is

switched on by the action of
thrombin.
Thus, thrombin has a dual function:
it catalyzes the formation of fibrin
and it initiates the deactivation of
the clotting cascade.

Coagulation factors and related

substances
I fibrinogen Forms clot (fibrin(
(II (prothrombin Its active form (IIa) activates I, V, VII, VIII,
XI, XIII, protein C, platelets
Tissue factor Co-factor of VIIa (formerly known as factor III)
Calcium Required for coagulation factors to bind to
phospholipid (formerly known as factor IV
)V (proaccelerin, labile factor )Co-factor of X with which it
forms the prothrombinase complex

XII (Hageman factor) Activates factor XI and

prekallikrein

XIII (fibrin-stabilizing factor) Cross links fibrin

von Willebrand factor
platelet adhesion

Binds to VIII, mediates

Prekallikrein Activates
cleaves HMWK

XII

and

prekallikrein;

high molecular weight kininogen (HMWK) Supports

reciprocal activation of XII, XI, and prekallikrein

 antithrombinIII Inhibits IIa, Xa, and other

proteases
heparin cofactor II Inhibits IIa, cofactor for
heparin
protein C Inactivates Va and VIIIa
protein S Cofactor for activated protein C

Specific inhibitors of
clotting factors
1.Antithrombin III is the most important one,
It is a plasma protein that inactivates thrombin by
forming an irreversible complex with it.
It resembles alpha 1-antitrypsin except that it
inhibits thrombin much more strongly than it inhibits
elastase.
Also, it blocks other serine proteases in the clotting
cascade namely, factors XIIa, XIa, IXa, and Xa.

2.Heparin
The inhibitory action of antithrombin III is enhanced
by heparin
It is a negatively charged polysaccharide found in
mast cells near the walls of blood vessels and on
the surfaces of endothelial cells
Heparin acts as an anticoagulant by increasing the
rate of formation of irreversible complexes between
antithrombin III and the serine protease clotting
factors.
Antitrypsin and antithrombin are serpins, a family
of serine protease inhibitors.

3. Alpha 1-antitrypsin
which normally inhibits elastase
alpha 1-Antitrypsin activity normally increases
markedly after injury to counteract excess elastase
arising from stimulated neutrophils.
The mutant a 1-antitrypsin caused the patient's
thrombin activity to drop to such a low level that
hemorrhage ensued.

Disease and clinical significance

of thrombosis
1.

Hemophilias

are the
coagulation factor disorders.

best-known

The three main forms are:

hemophilia A
)factor VIII deficiency(
hemophilia B
(factor IX deficiency or
"Christmas disease")

hemophilia C
, factor XI deficiency(
).mild bleeding tendency

 2. von Willebrand disease

It is the most common hereditary bleeding disorder
and is characterized as being inherited autosomal
recessive or dominant.
In this disease there is a defect in von Willebrand
factor (vWF) which mediates the binding of
glycoprotein Ib (GPIb) to collagen.
This binding helps mediate the activation of
platelets and formation of primary hemostasis.

3. Deficiency of Vitamin K
It may also contribute to bleeding disorders
because clotting factor maturation depends
on Vitamin K.

4. Liver diseases:
Some clotting factors; II, IX, VII, X are
synthesized in liver
Liver diseases
deficiency of these
factors
bleeding disorders.