Blood Clotting:

Dr. Weilersaid that if we know his notes, and review his exam questions, we will do
great.

Stages of hemostais:

• Primary Hemostasis:
○ Initiated upon structural damage to vascular endothelium
○ Instantaneous response
○ Mediated by rapid adhesion, activation and aggregation of blood
platelets
○ Initial platelet-dependent process does not involve enzymatic reactions
• Secondary Hemostasis:
○ Enzymatic response
○ Converts soluble fibrinogen molecules into sticky fibrin
 Sticky fibrin is insoluble
 Forms glue that stabilizes platelet clot
○ Takes longer than primary response
• Wound Healing
○ Blood clot is remodeled and removed
○ De-clotting of fibrinolytic enzymes
○ Angiogenesis and tissue remodeling

Platelets (thrombocytes):

• Derived from polyploidy progenitor cells in bone marrow

○ Name of the polyploidy progenitor cell is **megakaryocyte
• Megakaryocytes are fragmented to create platelets
○ No nucleus in fragments
• Structure:
○ Large surface area
○ Granules that store metabolites, proteins and hemostasis enzymes
○ Surface receptors for adhesion molecules, coagulation factors and
ligands that modify fxn.
• Adhesion:
○ Involves platelet surface receptor **(GP1alpha) for adhesion molecule
(von Willebrand factor)
○ vWF binds to areas where endothelia cells are injured
 **binds to exposed extracellular collagen fibers
• undergoes molecular change that enables vWF’s ability to
interact with platelet GP1b
○ this accumulates and adheres platelets at the injury
site
  activates platelets to change shape and
release ADPattracts more platelets
 Platelets receptors for various agonists
activate platelets and lead to thrombus
formation
○ Platelets Receptors:
 ADP, Thrombxoane A2, thrombin, epinephrine, collagen,
prostaglandin12.
○ The engagement of platelet receptors makes them
stickier for fibrinogen.
 Fibrinogen becomes converted to fibrin and clot is formed
○ Inherited Bleeding Disorders
 Glanzmann Thrombasthenia-defect in fibrinogen receptor
GPIIbIIIa
 Von Willebrand disease: defect in vWF
 Bernard-Soulier Syndrome: defect in GP1balpha
○ Aggregometer-tests the function of platelets and molecules important
in the clot process
 Platelets are incubated with agonists
• ADP, thrombin or collagen
○ Coagulation Factor:
 Secreted by liver as zymogens and activated by cleavage
 Activated coagulation factors cleave and activate other
coagulation factors
 Vitamin K:
• Needed as a cofactor in post-translational carboxylation
reactions
○ Essential to enable the coagulation factors to
interact with the injured cell’s membrane
○ Warfarin: inhibits the vitamin K-dependent
modification of clotting factors
 Is an anticoagulant
 Fibrinogen
• Very abundant and assemble into one large molecule
• Creates fibrin when fibronogens’s amino-terminals are
cleaved
○ Cleavage allows assembly of fribrinogen forms
fibrin
○ Fibrin is cross linked to other fibrin molecules
 Stabilizes fibrin
 Catalyzed by factor XIII

Coagulation Reaction
 • Conversion of zymogencoagulation factors into active proteases.
• Results in the generation of thrombin
○ Thrombin converts fribrinogen into insoluble fibrin
○ A little thrombin can signal a cascade to produce a lot of fibrin
• 3 stages of coagulation reaction:
○ Initiation
 Occurs upon contact of the membrane’s tissue factor with
coagulation VII
• TF-VII complex activates other factors
○ These assemble on surface of platelets into two
enzyme complexes
 Tenase and prothrombinase
○ Amplification of reaction occurs via thrombin
○ Reaction is terminated by anticoagulation mechanisms
○ Antithrombin, tissue factor pathway inhibitor, and
thrombomdulin-protein c pathway
• Intrinsic verse extrinsic pathway
○ Intrinsic
 Blood spontaneously forms a clot in a glass test tube
 Not required for coagulation initiation but is important in
amplification
○ Extrinsic
 In vivo pathway of coagulation initiation
 Occurs upon contact of factor VII with Tissue Factor (TF)
• TF is expressed when tissue is damage

Anticoagulation Pathways:

• Thrombin generation remains localized to sites of platelet deposition

• Antithrombin
○ Protease inhibitor of thrombin and activated factor
○ Forms TAT
 Irreversible complex with thrombin
 Increases 1000 fold in presence of heparin
• Binds antithrombin and thrombin
○ Antithrombin is the anticoagulant activity of
heparin
• Tissue Factor Pathway Inhibitor
○ Inhibits the extrinsic initiation reaction of coagulation
 Therefore, thrombin must be sustained via the amplification
reaction which is independent of TF
○ Inhibits the initiation complex of coagulation b/w TF and VIIa and
factor Xa
 • Protein C anticoagulant Pathway
○ Is initiated upon binding of thrombin to the endothelial membrane’s TM
molecule.
 Alters substrates preference of thrombin:
• Thrombin is unable to activate fibrinogen
• Cleaves zymogen protein c and generates activated
protein c (APC)
• APC inactivates ten-ase and prothrombinase
○ Fv Leiden mutation
 Mutation in coagulation factor V
 Most common cause of venous thrombosis in Caucasians
 Factor V is resistant to APC and patient is prone to clot formation

Fibrinolysis:

• Enzymatic degradation of fibrin and dissolution of clots

• Key enzyme=plasmin
○ Cleaves fibrin fibrils into fibrin degradation products
○ Generated from zymogen plasminogen and tPA
 Tpa and bacterial activators of plasminogen are important drugs
that break down severe clots in stroke and MI patients
○ Regulated by inhibitors

Know Bleeding disorders

Thrombosis Risk Factors

• Low vWF
• Low Proein S
• Low Protein C
• Low AT III (pregnancy)
• High prothrombin (sepsis)
• High factor IX
○ APC resistance (factor V leiden)
○ Lupus anticoagulant

Therapeutic Approaches:

• To control bleeding:
○ Transfusion of blood products containing platelets and/or coagulation
factors
○ Administration of purified coagulation factors to hemophilia patients
and those with von willebrand disease
○ Purified factor VII to trauma patients
 Prevents blood loss and brain hemorrhage
 • Thrombosis
○ Aniticoagulants
○ Fibrinolytic agents

Laboratory Evaluation of coagulation/fibrinolysis

• Whole blood clotting time

○ Prothrombin Time
○ Global Platelet function tests
 International Normalized Ratio
• Platelet Count
○ APC resistance test
○ Platelet fxn tests
○ Drug-induced platelet antibodies
• Genetic screening

Practice Test Questions:

1. In individuals carrying the factor V Leiden mutation, the risk of thrombosis is:

A. increased.

B. decreased.

C. unaltered.

1. Warfarin inhibits the function of:

A. vitamin K-independent clotting factors.

B. platelets.

C. vitamin K-dependent clotting factors.

D. von Willebrand factor.

1. Von Willebrand factor binds to which of the following to thereby mediate the
attachment of platelets to sites of blood vessel injury?

A. Fibrinogen.
B. Thrombin.

C. ADP.

D. Plasminogen.

E. Thrombomodulin.

F. Collagen.

1. Hemophilia B is caused by the lack of coagulation factor:

A. XI.

B. X.

C. IX.

D. VIII.

E. VII.

1. "International Normalized Ratio" (INR) expresses a measurement of:

A. number of platelets in a given volume of blood.

B. blood clotting time.

C. number of erythrocytes in a given volume of blood.

Answers: A, A, F, C, B

2007 exam
31. Platelets originate by fragmentation of:

A. hematopoietic stem cells.

B. red blood cell precursors.

C. polyploid megakaryocytes.
 Answer: C

32. Thrombophilia may result from:

A. vitamin K deficiency.

B. von Willebrand factor deficiency.

C. the "Leiden" mutation in coagulation factor V.

D. Factor VIII deficiency.

E. Factor V deficiency.

Answer: C

Definition of Thrombophilia: propensity to develop blood clots

33. The anticoagulant activity of heparin is mediated by:

A. Tissue type plasminogen activator.

B. Fibrin(ogen).

C. Thrombin.

D. Tissue factor pathway inhibitor (TFPI).

E. Antithrombin.

F. Thrombomodulin.

G. Dependent.

H. Independent.

I. Glycoprotein 1b-complex (GP1b).

J. Factor VIII.

K. Factor IX.

L. Factor X.
Answer: E

34. Warfarin suppresses the activity of Vitamin K-….. clotting factors?

A. Tissue type plasminogen activator.

B. Fibrin(ogen).

C. Thrombin.

D. Tissue factor pathway inhibitor (TFPI).

E. Antithrombin.

F. Thrombomodulin.

G. Dependent.

H. Independent.

I. Glycoprotein 1b-complex (GP1b).

J. Factor VIII.

K. Factor IX.

L. Factor X.

Answer: G

35. Hemophilia A is caused by a genetic defect in:

A. Tissue type plasminogen activator.

B. Fibrin(ogen).

C. Thrombin.

D. Tissue factor pathway inhibitor (TFPI).

E. Antithrombin.

F. Thrombomodulin.

G. Dependent.

H. Independent.

I. Glycoprotein 1b-complex (GP1b).

 J. Factor VIII.

K. Factor IX.

L. Factor X.

Answer: J

36. Bernard-Soulier disease is caused by a genetic defect in:

A. Tissue type plasminogen activator.

B. Fibrin(ogen).

C. Thrombin.

D. Tissue factor pathway inhibitor (TFPI).

E. Antithrombin.

F. Thrombomodulin.

G. Dependent.

H. Independent.

I. Glycoprotein 1b-complex (GP1b).

J. Factor VIII.

K. Factor IX.

L. Factor X.

Answer: I

34. Glanzmann’s thrombasthenia is caused by a defect in the platelet receptor for:

A. IX.

B. VII.
 C. Bernard-Soulier Syndrome.

D. Von Willebrand Disease.

E. fibrinogen.

F. VIII.

35. Hemophilia A is caused by the lack of coagulation factor:

A. IX.

B. VII.

C. Bernard-Soulier Syndrome.

D. Von Willebrand Disease.

E. fibrinogen.

F. VIII.

36. Heparin enhances the inactivation of thrombin by:

A. fish oil diet.

B. vitamin K-dependent clotting factors.

C. vitamin K-independent clotting factors.

D. antithrombin.

E. hirudin.

F. aspirin.

G. streptokinase.

37. Warfarin inhibits the function of:

A. fish oil diet.

B. vitamin K-dependent clotting factors.

C. vitamin K-independent clotting factors.

 D. antithrombin.

E. hirudin.

F. aspirin.

G. streptokinase.

38. Thromboxane A2 synthesis in platelets can be IRREVERSIBLY inhibited by:

A. fish oil diet.

B. vitamin K-dependent clotting factors.

C. vitamin K-independent clotting factors.

D. antithrombin.

E. hirudin.

F. aspirin.

G. streptokinase.

39. The risk for developing venous thrombosis in individuals carrying the factor V Leiden is:

A. increased.

B. decreased.

C. unaltered.