J Appl Physiol 115: 5763, 2013.

First published April 25, 2013; doi:10.1152/japplphysiol.00187.2013.

Effects of a single bout of walking exercise on blood coagulation parameters

in obese women
Manfred Lamprecht,1,2 Herve Moussalli,1 Gerhard Ledinski,1 Bettina Leschnik,3 Axel Schlagenhauf,3
Martin Koestenberger,3 Guenter Polt,2 and Gerhard Cvirn1
1

Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria; 2Green Beat-Institute of Nutrient Research
and Sport Nutrition, Graz, Austria; and 3Department of Pediatrics, Medical University of Graz, Graz, Austria
Submitted 11 February 2013; accepted in final form 19 April 2013

Lamprecht M, Moussalli H, Ledinski G, Leschnik B, Schlagenhauf A, Koestenberger M, Polt G, Cvirn G. Effects of a single bout
of walking exercise on blood coagulation parameters in obese women.
J Appl Physiol 115: 57 63, 2013. First published April 25, 2013;
doi:10.1152/japplphysiol.00187.2013.Obesity is associated with increased prevalence of thromboembolic events. We aimed to investigate whether obese women might benefit from vigorous aerobic
exercise. Forty-two overweight and obese women performed a 30-min
walking exercise test (treadmill ergometer) at an intensity of 70% of
individual peak oxygen uptake. Blood samples were collected before
and immediately after exercise. Thrombelastometry and platelet function measurements were performed on whole blood. Standard coagulation times, thrombin generation curves, markers of thrombin generation,
fibrinolytic parameters, plasma levels of pro- and anticoagulatory factors,
and microparticle procoagulant activity were determined in platelet-poor
plasma samples. Thrombelastometry revealed a significant prolongation
of clot formation time (P 0.037) and a significant deceleration of
fibrin build up (alpha angle, P 0.034) after exercise. Calibrated
automated thrombography revealed a significant exercise-induced
decrease in endogenous thrombin potential (P 0.039). Moreover,
thrombin formation stopped earlier postexercise, reflected in shortened StartTail (P 0.046). Significantly elevated tissue-plasminogen
activator levels (P 0.001) indicate an exercise-induced activation of
the fibrinolytic system. White blood cell count increased significantly
from pre- to postexercise (P 0.045), indicating a mild exerciseinduced leukocytosis. The results of this study demonstrate that
vigorous aerobic exercise might be a suitable tool to protect obese
women from thrombotic events. We show that a single bout of
vigorous aerobic exercise is clearly associated with an activation of
the fibrinolytic system and a decreased readiness of the postexercise
samples to form a clot and to generate thrombin, the pivotal enzyme
of hemostasis.
coagulation; exercise; obese women; thrombelastometry; thrombin
generation

(CVD) is a major cause of mortality

and morbidity in the Western world. Obesity and sedentary
lifestyle have been shown to be associated with increased
prevalence of CVD and disturbed hemostasis (24, 39). As a
consequence, official recommendations suggest that each individual should conduct 20 60 min of cardiorespiratory exercise
35 days/wk (8, 15, 20). These official recommendations are
based on studies demonstrating that vigorous physical exercise reduces the risk of CVD by tipping the delicate balance
between coagulation and fibrinolysis toward an anticoagulant
state (44).

CARDIOVASCULAR DISEASE

Address for reprint requests and other correspondence: G. Cvirn, Institute of

Physiological Chemistry, Medical Univ. of Graz, Harrachgasse 21/II, 8010
Graz, Austria (e-mail: gerhard.cvirn@medunigraz.at).
http://www.jappl.org

The majority of the studies suggesting an anticoagulant

effect of vigorous exercise were performed in young and
healthy men, so are not applicable to obese women. The aim of
this study was to quantify coagulation changes in response to
a single controlled exercise bout with vigorous intensity at 70%
O2) in obese premenoof individual peak oxygen uptake (V
pausal Austrian women at risk for thromboembolic complications (34).
Most studies dealing with the effects of exercise on hemostasis were performed in platelet-poor plasma (PPP) samples.
However, while PPP contains many of the coagulation factors
implicated in the coagulation process, whole blood (WB)
includes phospholipid-bearing cells and platelets, which support coagulation. Therefore, in the present study, hemostatic
profiling was performed in both WB samples (blood cell
counts, course of clot development, platelet function) as well as
in PPP samples [coagulation times, i.e., activated partial thromboplastin time (APTT) and prothrombin time (PT)]; thrombin
generation curves; markers of thrombin formation; fibrinolytic
parameters; levels of the pro- and anticoagulatory factors; and
microparticle procoagulant activity.
MATERIALS AND METHODS

Subjects. Forty-two overweight and obese women participated in

this trial. Inclusion criteria were as follows: female, age 3550 yr, preor perimenopausal, eligible to participate in exercise, nonsmokers,
sedentary work and lifestyle, body mass index between 28 and 40
kg/m2, no dietary or nutritional supplement use within 4 wk prior to
the walking exercise test. Exclusion criteria were as follow: smokers,
women who failed exercise eligibility testing as described by the
Austrian and German standards in sports medicine (8), chronic or
excessive alcohol consumption, recent surgery or illness, diabetes,
dyslipemia, current participation in a weight management program,
diagnosis of osteoporosis or osteopenia, and current use of any
medication known to significantly influence hemostasis. In addition to
these inclusion and exclusion criteria, a standard blood chemistry
O2 were determined in
panel, exercise echocardiography, and peak V
all women to confirm general health prior to study enrollment (for
subject characteristics, see Table 1). All subjects also completed a
medical history and a physical activity/well-being questionnaire.
Ethical aspects and recruitment. All subjects provided written
informed consent prior to participating in this investigation. This
study was conducted according to the guidelines of the Declaration of
Helsinki for research on human subjects 1989 and was approved by
the Ethical Review Committee of the Medical University of Graz,
Austria. The trial was registered under www.clinicaltrials.gov, identifier: NCT01476033.
The study focused on office workers and was announced in local
newspapers. A telephone screening conducted by the study staff
resulted in 59 volunteers for further eligibility testing. From those, 42

8750-7587/13 Copyright 2013 the American Physiological Society

57

58

Exercise and Coagulation in Obese Women

Table 1. Baseline characteristics, performance, and clinical

chemistry data of 42 premenopausal, obese, but otherwise
healthy, women
Variable

Age, yr
BMI, kg/m2
Weight, kg
O2, ml
Peak V
O2, ml kg1 min1
Peak V
VT, ml
O2
VT, % of peak V
O2, ml
70% of peakV
O2, % of VT
70% of peakV
Pmax, km/h slope (%)
P683.1% peakVO2, km/h
Clinical chemistry:
Glucose, mmol/l
Hemoglobin, g/l
Iron, mol/l
Ferritin, g/l
Cholesterol, mmol/l
HDL, mmol/l
Triglycerides, mmol/l

Reference Range*

42 Women

41.1 3.8
34.4 4.2
92.0 12.1
2,198 147
25.8 3.6
1,952 145
88.8 7.5
1,539 128
78.9 8.3
6 7 (1.77)
6 0.59
3.96.1
115155
1129
18300
6.35
0.802.35
1.80

5.1 1.5
128 14
16.8 5.7
79.9 57.5
5.57 1.33
1.17 0.28
1.37 0.58

O2, oxygen
Data are presented as means SD. BMI, body mass index; V
uptake; VT, ventilatory threshold; HDL, high-density lipoprotein; Pmax, maximum
O2 expressed via speed.
performance; P683.1% peak VO2, performance at 68% peak V
*See Ref. 40.

women met the inclusion and exclusion criteria and were enrolled in
the study program.
Study design and time schedule. This was a controlled clinical
intervention study. All eligibility testing was finalized 4 wk prior to
the 30-min walking exercise test. On the morning of the exercise test
a standardized breakfast (23 h prior to exercise) was provided. The
women came to the laboratory to perform the 30-min walking exercise
O2. All subjects were
test with an intensity of 70% of individual peak V
checked by a physician before each exercise test. The walking tests
were scheduled between days 10 and 20 of the menstrual cycle.
Incremental exercise tests. As part of eligibility testing each
woman performed an incremental exercise test on a treadmill ergometer (QUASARmed, HP Cosmos Sports and Medical, Traunstein,
Germany) to check heart and circulatory functions and for determi O2. Subjects started at 3 km/h on the treadmill for 3
nation of peak V
min (0% slope). After 3 min, women walked at 3.2 km/h on the first
step for 1 min. Each minute we increased treadmill velocity 0.4 km/h
until 6 km/h. From 6 km/h on we did not increase speed anymore (to
ensure walking technique/coordination) but increased the slope 1%
each minute for women who could maintain performance. Last step
and exhaustion were achieved when subjects were no longer able to
maintain walking speed/performance. A standard electrocardiogram
was recorded during the entire test, which was supervised by a
physician. Blood pressure (RR) was measured at the beginning,
during, and the end of the test.
Respiratory gas exchange and heart rate monitoring. Respiratory
gas exchange (RGE) variables were measured throughout the incremental exercise tests using a breath-by-breath mode (Metalyzer 3B,
Cortex Biophysik, Leipzig, Germany). During these tests, subjects
O2, carbon dioxide output (V
CO2),
breathed through a facemask. V

minute ventilation (VE), breathing rate (BR), and tidal volume (VT)
were continuously obtained. Heart rate (HR) was monitored throughout the tests using a commercially available HR monitor (Polar
Vantage NV, Polar Electro Finland).
Thirty-minute walking exercise test. For the 30-min aerobic walking exercise tests individual walking speed was adjusted to 70% of
O2 for 30 min on the same treadmill ergometer. All
individual peak V
exercise tests were carried out 23 h after a standardized breakfast.

Lamprecht M et al.

Similar to the maximal test, subjects completed a warm up phase at 3

km/h on the treadmill ergometer for 3 min. Thereafter, exercise was
pursued at 3.2 km/h and work rate was increased by 0.4 km/h every
O2 was reached, as
minute until the workload at 70% of peak V
calculated from the incremental step test. The test stopped after 30
min of defined exercise. Eight weeks later this procedure was repeated on
the same treadmill, under standardized room temperature (20C) and
humidity (60%). Electrocardiogram was recorded during the entire test,
which was supervised by a physician. Blood pressure (RR) was measured
at the beginning, after 10 and 20 min, and at the end of the test.
Collection of WB and preparation of plasma. Each subject had
blood collected in the supine position from a medial cubital vein
before exercise (Pre) and immediately after exercise (Post). Blood
(2.7 ml) was collected into precitrated S-Monovette premarked tubes
(3 from each individual) from Sarstedt (Nmbrecht, Germany), containing 300 l of 0.106 mol/l sodium citrate. The first tube was
discarded. The whole blood from the two remaining tubes was pooled
and subsequently used for determination of blood cell counts as well
as for thrombelastometry and platelet function measurements. The
remaining WB was centrifuged at room temperature for 15 min at
1,200 g to obtain PPP for subsequent determination of standard
coagulation times, thrombin generation curves, markers of thrombin
generation, fibrinolytic parameters, plasma levels of pro- and anticoagulatory factors, and microparticle procoagulant activity.
Blood cell counts. Blood cell counts were determined on a Sysmex
KX-21N Automated Hematology Analyzer from Sysmex.
WB tissue factor triggered thrombelastometry assay. The thrombelastometry (TEM) coagulation analyser (ROTEM 05) (Matel Medizintechnik, Graz, Austria) was used to measure coagulation time (CT), the
time from initiation of the test to the initial fibrin formation; clot
formation time (CFT), the time from the beginning of clot formation until
the amplitude of thrombelastogram reaches 20 mm; maximum clot
firmness (MCF), the maximum strength in millimeters of the final clot;
and alpha, the angle between the line in the middle of the TEM tracing
and the line tangential to the developing body of the TEM tracing. The
alpha angle represents the acceleration (kinetics) of fibrin build up and
cross-linking. This method has been described in detail recently (37).
WB platelet aggregation assay. Whole blood aggregation assessments were performed using a Chrono-Log Whole Blood Aggregometer model 590 from Probe and Go (Endingen, Germany), which is
based on the impedance method (30, 32). Impedance aggregometry
results are expressed as amplitude (or maximum aggregation) in
ohms at 6 min after reagent addition and as lag time (or aggregation time) in seconds, the time interval until the onset of platelet
aggregation. The rate of platelet aggregation is expressed as slope
in ohms per minute. Collagen was used as platelet agonist, as
previously described (11).
WB platelet adhesion assay. Platelet adhesion was assessed using a
Cone and Platelet Analyzer (CPA) (DiaMed, Linz, Austria). The
method has been described previously (41). Briefly, 130 l of citrated
WB is placed in polystyrene tubes and allowed to flow (1,300 s1) for
2 min using a rotating Teflon cone. The wells were washed with
phosphate-buffered saline, stained with May-Grnwald solution and
analyzed with an image analysis system. The three platelet function
values, i.e., surface coverage (SC), average size (AS), and number of
adhering objects (objects), were evaluated. SC is expressed as the
percentage of total area covered by platelets. Average size is defined
as the average size of the surface bound objects (28).
APTT and PT. Both APTT and PT were measured on the optomechanical Behring Fibrintimer (Behring Diagnostics, Marburg, Germany) coagulation analyzer. PT results are reported as international
normalized ratio (INR).
Automated fluorogenic measurement of the thrombin generation.
Thrombin generation curves were monitored using calibrated automated
thrombography (CAT) (Thrombinoscope BV, Maastricht, the Netherlands) (22). The ability of a given plasma sample to generate thrombin
was assessed with respect to lag time preceding the thrombin burst (Lag

J Appl Physiol doi:10.1152/japplphysiol.00187.2013 www.jappl.org

Exercise and Coagulation in Obese Women

time), time to peak (ttPeak), peak height (Peak), and endogenous thrombin potential (ETP), and the time point at which free thrombin has
disappeared (StartTail). Measurements were carried out in the presence of
5 pmol/l of tissue factor (TF) (final concentration).
Markers of thrombin generation. Plasma levels of prothrombin
fragment 12 (F 12) and thrombin-antithrombin complexes (TAT)
were determined using ELISA kits from Behring Diagnostics (Marburg, Germany).
Fibrinolytic values. Plasma levels of tissue-plasminogen activator
(t-PA) and plasminogen activator inhibitor-I (PAI-I) were determined
using the assays IMUBIND tPA ELISA kit and IMUBIND PAI-I
Plasma ELISA, respectively, from American Diagnostica (Pfungstadt,
Germany).
Procoagulatory factors. Plasma levels of prothrombin (FII), FVII,
and FVIII were determined on a BM/Hitachi 917 from Roche (Vienna, Austria). TF was determined by means of the assay ACTICHROME Tissue Factor ELISA from American Diagnostica.
Anticoagulatory factors. Plasma levels of tissue factor pathway
inhibitor (TFPI) were determined using the ACTICHROME Total
TFPI ELISA assay from American Diagnostica.
Microparticle procoagulant activity. Microparticle procoagulant
activity was determined using the functional assay ZYMUPHEN
MP-Activity from HYPHEN BioMed (Neuville, France) on a Microplate Scanning Spectrometer (Bio-Tek Instruments, Winooski, VT).
Plasma samples, supplemented with calcium, FXa and FIIa inhibitors were introduced to microplate wells coated with streptavidin
and biotinylated annexin V. Then FXa-FVa mixtures containing
calcium and purified prothrombin were introduced. Microparticles
bind to annexin V and expose their phospholipid surface, thus
allowing conversion of prothrombin to thrombin. Phospholipid
concentration is the limiting factor. The amount of thrombin
generation, reflecting the phospholipid concentration, is measured
via its specific activity on a chromogenic thrombin substrate.
Absorbance was measured at 405 nm.
Statistical analyses. All statistical analyses were performed using
SPSS for Windows software, version 19.0. Data are presented as
means SD. All data were adjusted for plasma volume changes as
described elsewhere (16). Statistical significance was set at P 0.05.
The Shapiro-Wilk test was used to determine normal distribution and
Levene test for homogeneity of variances. Pre- and postexercise data
were compared by paired Students t-test.

59

Lamprecht M et al.

Sample size calculation based on ETP and CFT estimated 37

subjects, depending on parameter, SD, and effect size, to reach a
probability of error (alpha/2) of 5% and 80% power. Allowing for a
O2 testing
drop-out rate of 10% during recruiting (between maximal V
and first walking test), 42 subjects were recruited for the study.
RESULTS

Thirty-minute controlled walking exercise. The postexercise

analyses revealed that women performed de facto at 68.2
O2 (which was determined 4 wk
3.1% of individual peak V
before). This demonstrates that the women could hold the
O2 over 30 min accurately.
preset intensity at 70% of peak V
The average walking speed was 6 0.59 km/h at this exercise
intensity. Performance and clinical chemistry data are shown in
Table 1.
Blood cell counts pre- vs. postexercise. WBC count increased significantly from pre- to postexercise (P 0.045),
indicating a mild exercise-induced leukocytosis (18). IL-6 and
TNF-alpha remained unchanged (data not shown). Red blood
cell count did not change, although there was a trend to
increased hematocrit and hemoglobin (P 0.077 and 0.072
respectively). Data are shown in Table 2.
Thrombelastometry values pre- vs. postexercise. Thrombelastometry values were compared pre- and postexercise with
respect to CT, CFT, MCF, and alpha angle. The 30-min
walking exercise caused a significant prolongation of CFT
(P 0.037) compared with preexercise and a significant
reduction of alpha angle (P 0.034). There were no differences concerning CT and MCF. CTs and CFTs in both pre- and
postexercise samples were slightly prolonged compared with
apparently healthy women (37). Data are shown in Table 2.
WB platelet aggregation pre- vs. postexercise. WB platelet
aggregation values were compared pre- and postexercise with
respect to amplitude, slope, and lag time. These parameters
were not affected by this model of exercise. Platelet aggregation in terms of amplitude and slope was slightly less pronounced in the obese women compared with apparently

Table 2. Coagulation values in WB samples prior and after the 30-min aerobic walking exercise test

Blood cell counts

WBC, 103 l1
RBC, 106 ml1
Hb, g/dl
Hct, %
Platelets, 103 ml1
Thrombelastometry
CT, s
CFT, s
MCF, mm
Alpha,
Platelet aggregation:
Lag time, s
Slope, ohms/min
Amplitude, ohms
Platelet adhesion
Surface coverage, %
Average size, m2
Objects, counts

Preexercise
(Mean SD)

Postexercise
(Mean SD)

Reference Values Mean (95 % Range)

or Mean SD

6.7 1.8
4.1 0.3
12.6 0.8
38.3 1.8
239 56

7.5 1.9
4.2 0.4
12.9 0.8
39.0 1.8
257 64

382 86
142 31
60.9 3.6
63.2 6.2

398 83
165 47
61.6 4.2
59.8 7.7

322 55b
119 28b
61.3 5b

0.1
0.037
0.1
0.034

133.1 95.1
9.6 4.8
12.1 3.1

131.6 84.4
10.2 4.4
12.9 3.2

58.6 9.7c
8.4 2.0c
13.6 1.4c

0.1
0.1
0.1

12.5 3.9
41.7 16.9
1,853 415

12.8 4.1
38.1 14.0
2,002 512

14.9 2.5d
39.4 5.2d
1,380e

0.1
0.1
0.1

7.0
4.5
13.5
42
250

(4.310.0)a
(3.55.5)a
(1215)a
(3648)a
(125318)a

Significance
(Pre vs. Post)

0.045
0.1
0.072
0.077
0.1

WB, whole blood; WBC, white blood cells; RBC, red blood cells; Hb, hemoglobin; Hct, hematocrit; CT, coagulation time; CFT, clot formation time; MCF,
maximum clot firmness; Pre, preexercise; Post, postexercise. See text for definition of alpha angle. aSee Ref. 21; bsee Ref. 11; csee Ref. 10; dsee Ref. 15; esee
Ref. 25. Boldface indicates significant difference, Pre vs. Post.
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60

Exercise and Coagulation in Obese Women

healthy adults; lag times were markedly prolonged compared

with healthy adults (11). Data are shown in Table 2.
WB platelet adhesion pre- vs. postexercise. WB platelet
adhesion values were compared pre- and postexercise with
respect to SC, AS, and number of objects. No differences were
found for these parameters. Platelet adhesion in terms of SC
and AS was comparable to that of healthy adults; number of
objects was higher in the obese women. Data are shown in
Table 2.
APTT and PT (INR) pre- vs. postexercise. No statistically
significant differences were found between pre- and postexercise. Data are shown in Table 3.
Thrombin generation values pre- vs. postexercise. Thrombin
generation was compared pre- and postexercise with respect to
Lag Time, ttPeak, Peak, ETP, and StartTail. In the postexercise
PPP samples, ETP was significantly decreased (P 0.039) and
thrombin formation ceased earlier, reflected in shortened StartTail (P 0.046). Lag Time, ttPeak, and Peak remained
unaffected by exercise. Data are shown in Table 3.
Markers of thrombin generation pre- vs. postexercise.
Plasma levels of F12 as well as of TAT were not affected by
the model of exercise. F12 levels were above normal in both
pre- and postexercise PPP samples. Data are shown in Table 3.
Fibrinolytic values pre- vs. postexercise. Significantly elevated t-PA levels (P 0.001) postexercise indicated an exercise-induced activation of the fibrinolytic system. Levels of
PAI-I were not affected by the model of exercise. Data are
shown in Table 3.
Levels of procoagulatory factors pre- vs. postexercise.
Plasma levels of FII and FVII were not affected by exercise.
However, both markers were distinctly above normal in both
pre- and postexercise samples. FVIII levels exceeded 168% in
both pre- and postexercise samples. No exercise-induced in-

Lamprecht M et al.

crease in plasma levels of TF was observed. Data are shown in

Table 3.
Microparticle procoagulant activity pre- vs. postexercise.
Microparticle procoagulant activity, evaluated by means of
enzyme-linked immunosorbent assay, was not affected by the
model of exercise. However, the values were distinctly above
normal in both pre- and postexercise PPP samples. Data are
shown in Table 3.
Concentration of anticoagulatory factors pre- vs. postexercise. Exercise did not cause significant changes in plasma
levels of TFPI. Levels of TFPI were lower than normal in both
pre- and postexercise PPP samples. Data are shown in Table 3.
DISCUSSION

Numerous studies, undertaken to examine the effects of

physical activity on hemostasis, report on both pro- as well as
on anticoagulant effects of exercise. A field synopsis leads to
the assumption that the hemostatic response to exercise is
mainly influenced by the intensity of exercise (26, 27, 39).
O2max) activates both the coagulation
Heavy exercise (83% V
and the fibrinolysis system (43) whereas vigorous exercise
O2max) is associated with an enhancement of fibrinoly(68% V
sis without a concomitant increase in markers of blood coagulation (44). Wang et al. (42) have shown that platelet adhesiveness and aggregation are upregulated by strenuous but not
by vigorous exercise.
In this study the aim was to investigate whether otherwise
healthy obese women, assumed to be at an elevated risk for
thrombotic events, might show a hemostatic benefit from a
controlled bout of vigorous exercise.
Hemostatic profiling of the preexercise PPP, but not of the
WB samples, suggests that, in accordance with the above-

Table 3. Coagulation values in PPP samples prior and after the 30-min aerobic walking exercise test
Coagulation times
APTT, s
INR
Thrombin generation
Lag time, min
ETP, nmol l1 min1
Peak, nmol/l
Time to peak, min
Starttail, min
Markers of thrombin generation
F1 2, pmol/l
TAT, g/l
Fibrinolytic values
t-PA Ag, ng/ml
PAI-1 Ag, ng/ml
Procoagulatory factors
F II, %
F VII, %
F VIII, %
TF, pg/ml
MP procoagulant activity, nmol/l
Anticoagulatory factor
TFPI, g/l

Preexercise Mean SD

Postexercise Mean SD

Reference Range

35.2 4.0
1

36.1 4.7
1

3040
1

2.07 0.5
1,981 311
479 56
3.8 0.7
19.2 2.0

2.1 0.3
1,840 304
463 59
3.7 0.6
18.4 2.1

3.1 1.4a
1,879 284a
458 60a

0.1
0.039
0.1
0.1
0.046

247.9 97.0
6.26 10.7

268.2 107.0
3.1 1.2

69229b
1.04.1b

0.1
0.064

6.4 2.2
16.5 13.9

8.6 3.1
15.1 11.6

1.48.4c
340c

0.001
0.1

145.1 24.6
143.0 34.9
168
187 59
19.1 13.1

148.1 22.0
142.6 35.2
168
195 64
21.9 15.2

70120
70120
70120
9.2 2.8d

0.1
0.1

0.1
0.1

49.8 17.1

49.5 16.3

60180e

0.1

Significance (Pre vs. Post)

0.1
0.1

PPP, platelet-poor plasma; APTT, activated partial thromboplastin time; INR, international normalized ratio; ETP, endogenous thrombin potential; F 12,
prothrombin fragment 12; TAT, thrombin-antithrombin complex; t-PA, tissue-plasminogen activator; PAI-1, plasminogen activator inhibitor I; TF, tissue
factor; MP, microparticles; TFPI, tissue factor pathway inhibitor. aSee Ref. 17; baccording to Dade Behring (unpublished observations); csee Ref. 9; dsee Ref.
30; esee Ref. 3. Boldface indicates significant difference, Pre vs. Post.
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Exercise and Coagulation in Obese Women

mentioned assumption, these women were in a hypercoagulable state compared with healthy, nonobese subjects. Preexercise plasma levels of F 12 were markedly higher than those
of healthy nonobese subjects, indicating elevated formation of
thrombin. Moreover, preexercise plasma levels of FII, FVII,
and FVIII were markedly higher than normal. Elevated plasma
levels of these three coagulation factors have been shown to be
associated with an increased readiness to form thrombin (4, 7,
22). Further evidence of a hypercoagulable state in these obese
women was the low level of TFPI. Low levels of TFPI have been
shown to have a procoagulant effect by facilitating the initiation of
thrombin generation (1, 4). Evidently, these obese women were
apparently in a hypercoagulable state prior to exercise due to a
markedly elevated procoagulant activity of microparticles compared with healthy young men (38). These results emphasize the
importance of an antithrombotic prophylaxis/treatment of obese
women.
The data show that regular vigorous exercise might be a
suitable tool to shift the hemostatic system of obese women
toward an anticoagulant state. 1) The fibrinolytic system was
significantly activated; and both the 2) clot-forming capacity as
well as the 3) thrombin-forming capacity were significantly
decreased in the postexercise samples.
1) Obesity-related atherothrombotic risk has been shown to
be associated with an impaired capability of endothelial cells to
release t-PA, the pivotal enzyme initiating the endogenous
fibrinolytic response (5, 40). The present study showed, in
accordance with others, significantly elevated t-PA levels in
the postexercise PPP samples (29, 36, 45). We conclude that
particularly obese women, known to be at an elevated risk for
thromboembolic complications, might benefit from the exercise-induced high plasma levels of t-PA known to enhance the
efficacy of endogenous fibrinolysis (23).
2) TEM measurements revealed an impaired clot-formation
capacity of the postexercise WB samples. CFTs were significantly prolonged and alpha angles were significantly lower in
the postexercise compared with the preexercise WB samples,
indicating impaired fibrin build up and cross-linking (37).
Presumably, this impaired clot formation is attributable, at least
in part, to the exercise-induced increase of t-PA. Several
groups have reported impaired clot development in the presence of increasing amounts of t-PA. Nielsen et al. (31) have
shown significantly decreased TTP (total thrombus generation)
in the presence of increasing amounts of t-PA. Ploppa et al.
(33) have shown significantly impaired clot formation in a
patient with a massive pulmonary embolism after administration of recombinant t-PA, and DAmico et al. (14) have shown
reduced MCFs and prolonged CTs in the presence of recombinant t-PA (1 g/ml).
3) CAT measurements revealed an impaired thrombin-forming capacity after vigorous exercise. Free thrombin was generated in significantly lower amounts (reflected by lower ETP
values) and disappeared significantly earlier (reflected by
shorter StartTails) in the postexercise PPP samples stimulated
by addition of TF. The underlying mechanisms leading to this
diminished capability of the postexercise PPP samples to
generate thrombin remain to be elucidated. The two most
reasonable explanations, decreased plasma levels of prothrombin and/or decreased plasma levels of TF, do not apply. It has
been shown that thrombin generation dose dependently decreases in the presence of decreasing amounts of prothrombin

Lamprecht M et al.

61

(2) as well as of TF (2, 22). However, in the present study, both

prothrombin and TF levels were virtually the same in the preand postexercise samples. Another explanation for the diminished capability of the postexercise PPP samples to generate
thrombin might be exercise-induced elevated levels of antithrombin (AT) or alpha 2-macroglobulin (a2-M), the two most
efficient inhibitors of thrombin (4). A dose-dependent decrease
of ETP in the presence of increasing amounts of AT and a2-M
has been shown previously (13). In the present study AT and
a2-M plasma levels were not determined. However, it is
unlikely that the vigorous exercise applied here resulted in
significantly elevated plasma levels of these two inhibitors.
Huisveld et al. (23) have shown elevated AT and a2-M levels
after exhaustive exercise, but that increase was completely
attributable to hemoconcentration, and Cerneca et al. (6) have
shown modest, yet significant, increases in AT levels after
exhaustive exercise in trained but not in untrained individuals.
Despite this, plasma levels of AT as well as of a2-M remain to
be monitored in future studies dealing with exercise and
coagulation.
In a similar study, Beltan et al. (2a) have shown a decrease
of APTT in healthy subjects after a 15 min duration exercise
conducted at almost the same intensity as in the present study
indicating no such decrease. It has been suggested that the
decrease of APTT is, at least partially, attributable to an
exercise-induced increase of FVIII coagulant activity. In contrast to the study of Beltan et al. (2a), our subjects were already
in a hypercoagulable state prior to testing, reflected by, e.g.,
increased levels of FVIII. Thus an exercise-induced increase of
already elevated FVIII levels apparently does not result in
shortened APTT. This assumption is supported by the findings
of van Veen et al. (47). They have shown that the procoagulant
action of FVIII dose dependently increases (by measuring
thrombin generation curves) within a range of 1 to 100% of
normal value and reaches a plateau at 150%.
Presumably, the anticoagulant effect of vigorous exercise
might be dampened by leukocytosis. In agreement with various
other studies this work showed significantly elevated WBC
counts (by 12%) in the postexercise WB samples (35).
Leukocyte procoagulant activity and the capability of leukocyte products to augment the ability of endothelial cells to
activate coagulation have been shown previously (17). However, this leukocytosis-induced procoagulant effect is modest
in this vigorous exercise experiment, although it might be of
importance in studies dealing with intense exercise (19).
At this time it is unknown how long the effect of a single
exercise bout on blood coagulation persists. Further research is
required to estimate the effects of standardized chronic exercise programs over several weeks or months on hemostasis in
obese women.
In conclusion, these findings demonstrate that a single bout
of vigorous aerobic exercise is clearly associated with an
activation of the fibrinolytic system and with a decreased
readiness of the postexercise samples to form a clot and to
generate thrombin, the pivotal enzyme of hemostasis.
ACKNOWLEDGMENTS
We thank Guenther Juergens, PhD, for revising the manuscript, and Anita
M. Boddie, PhD, for proofreading of the manuscript as a native English
speaker.

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62

Exercise and Coagulation in Obese Women

DISCLOSURES
No conflicts of interest, financial or otherwise, are declared by the author(s).
AUTHOR CONTRIBUTIONS
Author contributions: M.L. conception and design of research; M.L., H.M.,
G.L., B.L., A.S., M.K., G.P., and G.C. performed experiments; M.L., H.M.,
A.S., and M.K. analyzed data; M.L., H.M., G.P., and G.C. interpreted results
of experiments; M.L. and G.C. drafted manuscript; M.L., G.P., and G.C. edited
and revised manuscript; M.L., H.M., G.L., B.L., A.S., M.K., G.P., and G.C.
approved final version of manuscript; H.M., G.L., and B.L. prepared tables.
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