1. Discussed the structural and biochemical changes undergone by the coagulation proteins during clotting process.

Hemostasis is the cessation of bleeding from a cut or severed vessel, whereas thrombosis occurs when the endothelium
lining blood vessels is damaged or removed (e.g., upon rupture of an atherosclerotic plaque). These processes involve blood
vessels, platelet aggregation, and plasma proteins that cause formation or dissolution of platelet aggregates and fibrin.

Platelets normally circulate freely, suspended in plasma, in an inactivated state (disk shaped). The roles of platelets are to
(1) contribute to regulation of blood flow into a damaged site by induction of vasoconstriction (vasospasm); (2) initiate
platelet-platelet interactions, resulting in formation of a platelet plug to stop further bleeding; (3) activate the coagulation
(or clotting) cascade to stabilize the platelet plug; and (4) initiate repair processes including clot retraction and clot
dissolution (fibrinolysis). The normal platelet count ranges from 140,000 to 340,000/mm3.

The state of platelet activation is primarily under the control of endothelial cells lining the vessels. Damage to the vessel
initiates a process of platelet activation: (1) increased platelet adhesion to the damaged vascular wall; (2) activation leading
to platelet degranulation, which stimulates changes in platelet shape and biochemistry; (3) aggregation as platelet–vascular
wall and platelet-platelet adherence increases; and (4) activation of the clotting system and development of an immobilizing
meshwork of platelets and fibrin.

1. ADHESION
Platelet adhesion is mostly mediated by the binding of platelet surface receptor glycoprotein Ib (GPIb) (in
a complex with clotting factors IX and V) to von Willebrand factor (vWF).30 The vWF protein is found in the
subendothelial matrix and is released by endothelial cells and platelets. Platelet adhesion narrows the diameter of
the blood vessel, resulting in increasing shear forces that could strip platelets off the vessel surface. However, those
same forces induce conformational changes in the vWF molecule that result in increased affinity with GPIb, thus
stabilizing the adherent platelet.

2. ACTIVATION
As a result of interactions with the endothelium or the subendothelial matrix, as well as exposure to
inflammatory mediators produced by the endothelium and other cells, the platelets are activated. Activation results
in reorganization of the platelet cytoskeleton, leading to dynamic changes in platelet shape from smooth spheres to
those with spiny projections (increases surface area) and degranulation (also called the platelet-release reaction).
Platelets contain three types of granules: dense bodies, alpha granules, and lysosomes. The dense bodies
contain ADP, serotonin, and calcium. ADP recruits and activates other platelets through specific receptors. During
activation the platelet plasma membrane experiences several important changes, including becoming ruffled and
sticky; undergoing cellular spreading to make tight contacts between neighboring platelets, causing the platelet plug
to seal the injured endothelium; and externalizing the phospholipid phosphatidylserine, which provides a matrix for
activation of clotting factors. Serotonin is a vasoactive amine that functions like histamine and increases
vasodilation and vascular permeability. Calcium is necessary for many of the adhesive interactions as well as for
intracellular signaling mechanisms that control platelet activation.
Alpha granules contain a mixture of clotting factors (e.g., fibrinogen, factor V), growth and angiogenic
factors (e.g., platelet derived growth factor [PDGF], vascular endothelial growth factor [VEGF], basic fibroblast
growth factor), and angiogenesis inhibitors (e.g., platelet factor 4, thrombospondin, inhibitors of
metalloproteinases). Platelet factor 4 also is a heparin-binding protein and enhances clot formation at the site of
injury. Depending upon the particular stimulus, platelets may selectively release promoters or inhibitors of
angiogenesis. Many of these mediators either promote or inhibit platelet activity and the eventual process of clot
formation. PDGF stimulates smooth muscle cells and promotes tissue repair.
Platelet lysosomes have a role in the digestion of phagocytic and cytosolic components. Lysosomal contents
also may have important extracellular functions, such as supporting receptor cleavage, fibrinolysis and degradation
of extracellular matrix components, and remodeling of the vasculature.
Platelets also initiate production of the prostaglandin derivative thromboxane A 2 (TXA2), which counters
the effects of PGI2 produced by endothelial cells. TXA2 causes vasoconstriction and promotes the degranulation
of platelets, increases expression of platelet fibrinogen receptors, and stimulates platelet aggregation; whereas PGI
2 promotes vasodilation and inhibits platelet degranulation. An isoform of cyclooxygenase (COX-1) converts
arachidonic acid to TXA 2 in platelets. Aspirin at low doses specifically and irreversibly inactivates COX-1,
decreasing production of TXA2 and decreasing platelet activation and aggregation.
 Thrombin and collagen are particularly strong stimuli. Thrombin cleaves the extracellular domain of G
protein–coupled protease-activated receptors (PARs), thereby initiating transmembrane signaling.

3. Aggregation
Platelet aggregation is stimulated primarily by TXA2 and ADP, which induce functional fibrinogen
receptors on the platelet. The glycoprotein IIb/IIIa (GPIIb/IIIa) complex (also called integrin αIIbβ3) undergoes a
conformational change during activation to become a calcium-dependent receptor for fibrinogen. It is a member of
the integrin receptor family and binds other matrix proteins (e.g., fibronectin, fibrinogen, thrombospondin).
GPIIb/IIIa complex is the most abundant fibrinogen receptor on the platelet, receptors for vWF (GPIb) and collagen
(GPVI).
Interplatelet aggregation and clot retraction, which forms the primary hemostatic plug, are facilitated by
fibrinogen bridges between receptors on the platelets. The GPIIb/IIIa–fibrinogen pathway is essential for the
formation of a thrombus. In addition, fibrin strands within the clot shorten and become denser and stronger, helping
the clot to approximate the edges of the injured vessel wall and sealing the site of injury. Contraction of myosin and
actin filaments in the platelet cytoskeleton mediates platelet contraction and fusion of the platelet mass into a
secondary hemostatic plug. Contraction expels serum from the fibrin meshwork, resulting in greater packing and
increased strength. This process usually begins within a few minutes after a clot has formed, and most of the serum
is expelled within 20 to 60 minutes
If blood vessel injury is minor, primary hemostasis is achieved by formation of the platelet plug within 3
to 5 minutes of injury. Platelet plugs seal the many minute ruptures that occur daily in the microcirculation,
particularly in capillaries. If primary hemostasis is inadequate to prevent further bleeding, the process proceeds
through secondary hemostasis to create a larger complex of more tightly interactive platelets within a matrix created
by activation of the clotting system.

4. Activation of Clotting Factors and System

A blood clot is a meshwork of protein strands that stabilizes the platelet plug and traps other cells, such as
erythrocytes, phagocytes, and microorganisms. The strands are made of fibrin, which is produced by the clotting
(coagulation) system. The clotting system consists of a family of proteins that circulate in the plasma of the blood
in inactive forms (proenzymes). Initiation of the system results in sequential enzymatic activation (pathway) of
multiple members of the system until a fibrin clot is created.

The clotting system is commonly presented as two pathways of initiation: the extrinsic pathway (also known
as the tissue factor pathway) and the intrinsic pathway (also known as the contact activation pathway or the plasma
kallikrein-kinin system). These pathways join in a common pathway with activation of factor X, which proceeds to
thrombin, fibrin, and clot formation.

Tissue factor (TF) (also called tissue thromboplastin) is abundant in vascular sub endothelium and
adventitial cells surrounding larger blood vessels and body organs, particularly the skin, brain, lungs, kidney, and
placenta. There also are receptors for TF on activated monocytes. With vessel trauma and bleeding, TF binds with
high affinity to circulating activated factor VII (TF/VIIa), initiating the clotting pathway. TF is a transmembrane
protein that exists in an inactive form but is activated into an active enzyme with factors IX and X as substrates. TF
mediates a number of changes in disease-related activities, including inflammation, tumor angiogenesis metastasis,
cell migration, and clotting associated with atherosclerosis.

Factor XIIa (Hageman factor), prekallikrein (PK), and highmolecular-weight kininogen (HK; activates
factor XII) initiate the intrinsic coagulation pathway through activation of the downstream substrate factor XI. The
terms intrinsic or contact mean that the pathway is activated within the blood vessel by contact with anionic surfaces
(i.e., exposure of subendothelial collagen from vessel damage) or other substances without the action of TF. To be
further discussed on the 3 major stages of blood clotting mechanism. 1st stage: Factor Xa formation (both extrinsic
and intrinsic pathway), 2nd stage is thrombin formation and 3rd stage is fibrin formation.

Activated platelets are important participants in clotting. The phosphatidylserine-rich surface produced
during activation provides a matrix on which several important complexes of clotting factors are formed. These
include the intrinsic pathway's tenase complex (factor X and activated factors VIII and IX) that activates factor X
and the prothrombinase complex (prothrombin and activated factors X and V) that activates prothrombin into
thrombin (see Fig. 28.22). Thrombin then converts fibrinogen into fibrin, which polymerizes into a fibrin clot.
Thrombin has broad reactivity in the inflammatory response. In addition to producing fibrin, thrombin is an activator
of other coagulation proteins (e.g., factors V, VIII, XI, XIII), platelets (e.g., aggregation, degranulation), endothelial
cells (e.g., upregulation of adhesion molecules for leukocytes, increased NO, PGI2, PDGF), and monocytes (e.g.,
cytokine secretion, increased receptors for endothelial cells).
Vitamin K–dependent clotting factors include prothrombin (factor II) factors VII, IX, and X, and the
anticoagulation proteins (C and cofactors S and Z). These proteins undergo vitamin K–dependent γ- carboxylation
of glutamic acid residues that enables them to bind calcium and other divalent cations and participate in the clotting
pathways.