Cell-based model of haemostasis

P.I.T Patologi Klinik Bandung 2014

Heri Fadjari
Hematology-Medical Oncology Division
Hasan Sadikin General Hospital Bandung

Chapter

1. The haemostatic system

2. Primary haemostasis
3. Secondary haemostasis
4. Fibrinolysis

The haemostatic system: The three phases

Primary haemostasis:
Vasoconstriction (immediate)
Platelet adhesion (within seconds)
Platelet aggregation and contraction (within minutes)
Secondary haemostasis:
Activation of coagulation factors (within seconds)
Formation of fibrin (within minutes)
Fibrinolysis:
Activation of fibrinolysis (within minutes)
Lysis of the plug (within hours)

Colman RW, et al. Overview of haemostasis. In: Colman RW, Hirsh J, Marder VJ, Clowes AW, George JN, eds. Haemostasis and Thrombosis:
Basic Principles and Clinical Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001: 316.

Waterfall Cascade of Coagulation

PT test

PT prolonged by deficiency
of F VII, X, V, II or
Fibrinogen <100 mg/dL

aPTT test

Extrinsic

Intrinsic

HMWK
F XII
PK
F Xia
Ca++

F IXa
F VIIIa
Lipid

F VIIa
TF

Ca++
F IX

F XI

aPTT prolonged by
deficiency of any factors
but F VII

Ca++
FX

FX
FV

F Xa
F Va
Lipid

= Prothrombin

FIIa = Thrombin

Ca++
F II

FII

F IIa
F XIIIa
++
Clot
Fibrin Ca

FI

= Fibrinogen

Fia = Fibrin

Colman RW, et al. Overview of haemostasis. In: Colman RW, Hirsh J, Marder VJ, Clowes AW, George JN, eds. Haemostasis and Thrombosis:
Basic Principles and Clinical Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001: 316.

Limitations of the coagulation cascade

F XII deficiency cause prolongation of the
aPTT, but does not correlates w/ bleeding

Why does rhF VIIa control bleeding in

multiple common factor
deficiencies?
0

Why F XI deficiency the bleeding were

mild or even not bleed?

Inadequate to understanding anti plts

aggregation or thrombolytic therapy

Why does VII deficiency cause severe

bleeding when the intrinsic pathway is
intact?

HMWK
F XII
PK
F XIa
F IXa
F VIIIa
Lipid

F VIIa
TF

F XI
F IX

This does not mean that the PT and aPTT are useless.
We just need to understand what they can and cannot tell us.
F Xa
F Va
Lipid

FX

F II

FX
FV

F IIa
F XIIIa
Clot
Fibrin

Why Do Hemophiliacs Bleed?

The cascade model of coagulation does not explain why the
extrinsic pathway can not produce enough FXa to compensate for a
lack of factor VIII or IX, i.e. why cant FXa generated by FVIIa/TF
substitute for FXa generated by FIXa/VIIIa?
It has been hypothesized that this is due to:
TFPI shuts off the FVIIa/TF pathway before it can make enough
FXa to support generation of hemostatic amounts of thrombin.
Is not that enough FXa isnt made, but that it is made on the
wrong
cell surface.

Monroe DM, Hoffman M . Br J Haematol.2006;135:603-633. Shi Q et al. Blood. 2014;123(3):395-403

The haemostatic system

Hemostasis occurs only at the injury
site, DIC is an exception!
Hemostasis requires and involves
various physiological components:
The blood vessel wall
- Endothelial cells
- Subendothelial tissue
- Smooth muscle cells
The components of blood
- Platelets (thrombocytes)
- Coagulation (clotting) factors
- Anticoagulant proteins
- Leukocytes
Colman RW, et al. Overview of haemostasis. In: Colman RW, Hirsh J, Marder VJ, Clowes AW, George JN, eds. Haemostasis and Thrombosis:
Basic Principles and Clinical Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001: 316.

Chapter
1. The haemostatic system

2. Primary haemostasis
3. Secondary haemostasis
4. Fibrinolysis

Primary haemostasis - Vasoconstriction

The first response to
endothelial injury is the
constriction of the damaged
vessel which reduces the
blood flow at the site of
injury1

Monroe DM, Hoffman M. Arterioscler Thromb Vasc Biol 2006; 26(1): 4148.

Primary haemostasis - Formation of a platelet plug

The exposure of subendothelial components such as
collagen promotes platelet
adhesion

vWF
Collagen

TF

The adherence of platelets

to the sub-endothelium
and decrypted TF leads to
platelet activation and the
formation of platelet
aggregates (platelet plug)

Monroe DM, Hoffman M. Arterioscler Thromb Vasc Biol 2006; 26(1): 4148.

Encrypted vs Decrypted TF
Encrypted

Decrypted
PL Phosphatydil serine
Phosphatydil ethanolamine
Phosphatydil choline
Shyngomyelin

ATP

Flippase Floppase

Ca++

Flippase Scramblase

Tissue factor (TF), a cell surface transmembrane glycoprotein, is the

principal initiator of blood coagulation in vivo
Procoagulant activity is controlled by cellular mechanisms, that keep
TF in an inactive or encrypted state and regulate decryption after an
appropriate stimulus.
TF-bearing cells play a central role in hemostasis and thrombosis.
Bach RR. Arterioscler Thromb Vasc Biol 26: 456461, 2006. Ovanesov MV et al. J Thromb Haemost 2005; 3: 32131.

Chapter
1. The haemostatic system
2. Primary haemostasis

3. Secondary haemostasis
4. Fibrinolysis

Secondary haemostasis
Secondary haemostasis involves a series of interactions between
coagulation factors which occur on the surface of tissue-factorbearing cells and activated platelets1,2

This results in the generation of a thrombin burst and the

formation of a haemostatic plug at the site of vascular injury1,2
Based on the cell-based model, coagulation occurs in three
overlapping phases initiation, amplification and propagation1,2

1. Hoffman M, Monroe DM. Thromb Haemost 2001; 85(6): 958965.

2. Monroe DM, Hoffman M. Arterioscler Thromb Vasc Biol 2006; 26(1): 4148.

Secondary haemostasis - Initiation phase

Xa

TF

Va

VIIa
X

IX
IXa

1. Hoffman M, Monroe DM. Thromb Haemost 2001; 85(6): 958965.

2. Monroe DM, Hoffman M. Arterioscler Thromb Vasc Biol 2006; 26(1): 4148.

Secondary haemostasis - Amplification phase

Xa

Va

Prothrombin
TF

Thrombin

VIIa
IX

IXa

AT

Xa

TFPI

AT=Antithrombin III, TFPI= Tissue Factor Pathway Inhibitor

1. Monroe DM, Hoffman M. Arterioscler Thromb Vasc Biol 2006; 26(1): 4148.
2. Versteeg HH et al. Physiol Rev 93: 327358, 2013

Secondary haemostasis - Amplification phase

Xa

Va

Prothrombin
Thrombin
VIII

V
GpIb/IX
GpIIb/IIIa
PAR

PAR= Protease-Activated Receptors

1. Hoffman M, Monroe DM. Thromb Haemost 2001; 85(6): 958965.

2. Monroe DM, Hoffman M. Arterioscler Thromb Vasc Biol 2006; 26(1): 4148.

Secondary haemostasis - Amplification phase

Xa

Va

Prothrombin
Thrombin
V

VIII
Va

XIa

VIIIa
GpIIb/IIIa

IXa
IX

1. Hoffman M, Monroe DM. Thromb Haemost 2001; 85(6): 958965.

2. Monroe DM, Hoffman M. Arterioscler Thromb Vasc Biol 2006; 26(1): 4148.

Secondary haemostasis - Propagation phase

Fibrinogen
Thrombin

VIIIa
IXa

Xa
Va
Prothrombin

1. Monroe DM, Hoffman M. Arterioscler Thromb Vasc Biol 2006; 26(1): 4148.
2. Collet JP, et al. Arterioscler Thromb Vasc Biol 2000; 20(5): 13541361.

Secondary haemostasis Thrombin burst

The thrombin burst is particularly important because it:
Converts fibrinogen into fibrin monomers, which polymerise
and form the mesh-work basis of the haemostatic plug1,2
Activates more platelets and other factors, thereby further amplifying
the system1,2
Activates thrombin-activatable fibrinolysis inhibitor (TAFI)
which protects the plug from fibrinolysis1
Activates FXIII, which helps stabilising the haemostatic plug2

1. Bajzar L, Manuel R, Nesheim ME. J Biol Chem 1995; 270(24): 1447714484.

2. Monroe DM, Hoffman M. Arterioscler Thromb Vasc Biol 2006; 26(1): 4148.

Coagulation Factor XII

According to the cell biological model of coagulation, the intrinsic FXIFXII pathway only serves as an amplification loop initiated by the
extrinsic TF pathway1.
Three physiological triggers of the intrinsic pathway have been
discovered: collagen, polyphosphates, and neutrophil extracellular
traps (NETs)1.
FXII activation does not appear to lead to a faster clot formation, but
rather to increased fibrin clot stability. This could also explain why high
levels of FXII associate with thrombosis, while FXII deficiency may
render the clot unstable and lead to embolization2.

1. Van der Meijden PE et al. Blood 114: 881890, 2009. 2. Pauer HU. Thromb Haemost 92:503508, 2004.

Critical Role of Activated Platelets

FXa

Abciximab
Tirofiban

Thrombin

Rivaroxaban
Dabigatran

IIb/IIIA

Clopidogrel
Ticlopidin ADP
Prasugrel
Ticagrelor

TxA2 ASA

1. Hoffman M, Monroe DM. Thromb Haemost 2001; 85(6): 958965.

2. Monroe DM, Hoffman M. Arterioscler Thromb Vasc Biol 2006; 26(1): 4148.

Overview of Secondary Haemostasis

Thrombin
Thrombin

Activated
Platelet

Chapter
1. The haemostatic system
2. Primary haemostasis
3. Secondary haemostasis

4. Fibrinolysis

Fibrinolysis

TM
ATIII

FX

aPC

FVa
FXa

UFH
LMWH
Fondaparinux

Thrombin

FIa
Plasmin

Plasminogen

tPA
1. Hoffman M, Monroe DM. Thromb Haemost 2001; 85(6): 958965.
2. Monroe DM, Hoffman M. Arterioscler Thromb Vasc Biol 2006; 26(1): 4148.

These should be Kept in Mind!

Coagulation occurs not as a cascade, but in three overlapping stages:
1. Initiation, which occurs on a tissue factor bearing cell.
2. Amplification, in which platelets and cofactors are activated to set
the stage for large scale thrombin generation;
3. Propagation, in which large amounts of thrombin are generated
on the platelet surface.
In summary, thinking of coagulation as occurring on specific cell
surfaces can help us understand better the mechanism of normal
hemostasis as well as understanding the mechanisms by which
hemostasis fails in pathologic conditions.