Today we will finish the 3rd part of homeostasis; we talked about the blood vessel wall and their

role in maintaining homeostasis. Also we talked about platelets and their role. Now we will continue the subject by discussing the coagulation cascade.

Coagulation cascade
It is the third part of homeostasis. They are series of enzymatic conversions turning the inactive pro-enzymes into activated enzymes. It is composed of multiple proteins (they are named from factor 1 until 13; so factor 1 , factor 2 until factor 13). So all these factors are part of what we call the coagulation system (or reaction or cascade). These proteins or enzymes are synthesized usually in the liver and they are circulating in the blood. The main aim of the coagulation cascade is the formation of thrombin. Thrombin is the factor 2 (II) in the coagulation system, this thrombin will convert fibrinogen -which is soluble in the blood- into the insoluble fibrin. So this is the main aim of the reactions in the coagulation cascade. *Thrombin act on fibrinogen and convert it to fibrin to form fibrin clot*. Each reaction is composed of an enzyme, substrate and a co-factor. The substrate (which is a pro-enzyme) once it becomes activated, it will turn into an enzyme. So the enzyme was pro-enzyme or was a substrate of another enzyme. As we said the last or the final aim is to form thrombin, so thrombin is the main or major factor in the coagulation cascade . These components are assembled on a phospholipid complex and held together by calcium; Clotting factors are circulating in the blood, now once there is a site of injury or activation of the platelets, these activated platelets will attract these coagulation factors to their surfaces. Once these factors are on the surfaces of the activated platelets, they will start the coagulation process.
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Usually the clotting attends to remain localized to the sites of assembly; to the sites where the activation happened, usually on the activated platelets surfaces.

Number and/or name I (fibrinogen) II (prothrombin) IV (Calcium) V (proaccelerin, labile factor) VI VII (stable factor) VIII (antihemophilic factor) IX (Christmas factor) X (Stuart-Prower factor) XI (plasma thromboplastin antecedent) XII (Hageman factor) XIII (fibrin-stabilizing factor) von Willebrand factor prekallikrein Forms clot (fibrin)

Function Its active form (IIa) activates I, V, VIII, XI, XIII, protein C, platelets Required for coagulation factors to bind to phospholipid Co-factor of X with which it forms the prothrombinase complex Unassigned old name of Factor Va Activates IX, X Co-factor of IX with which it forms the tenase complex Activates X: forms tenase complex with factor VIII Activates II: forms prothrombinase complex with factor V Activates IX Activates factor XI and prekallikrein Crosslinks fibrin Binds to VIII, mediates platelet adhesion Activates XII and prekallikrein; cleaves HMWK

III (Tissue factor or thromboplastin Co-factor of VIIa

This molecular weight kininogen factors from factor 1 to factor 13. Each factor has a high table mentions all the Supports reciprocal activation of XII, XI, and prekallikrein (HMWK) specific name in addition to the number, also each factor has a specific function.
fibronectin Mediates cell adhesion Inhibits IIa, cofactor for heparin and dermatan sulfate ("minor antithrombin") Cofactor for activated protein C (APC, inactive when bound to C4bbinding protein)

Now the most important to know are: and other proteases; antithrombin III Inhibits IIa, Xa,
heparinFactor 1 (fibrinogen) o cofactor II protein Factor 2 (pro-thrombin) Inactivates Va and VIIIa o C

o S protein Factor 3

o Factor 8 Mediates thrombin adhesion to phospholipids and stimulates protein Z degradation of factor X by ZPI o Factor 10 . Protein Von willebrand factor is the one that connects the platelets to the collagen o Z-related protease inhibitor Degrades factors X (in presence of protein Z) and XI (independently) (ZPI) matrix. Also it participates here by binding to factor 8 (VIII).
plasminogen Converts to plasmin, lyses fibrin and other proteins Inhibits plasmin Activates plasminogen Activates plasminogen Inactivates tPA & urokinase (endothelial PAI) Inactivates tPA & urokinase (placental PAI) alpha 2-antiplasmin tissue plasminogen activator (tPA)

2urokinase |Page plasminogen activator inhibitor-1 (PAI1)

plasminogen activator inhibitor-2

X (Stuart-Prower factor) XI (plasma thromboplastin antecedent) XII (Hageman factor) XIII (fibrin-stabilizing factor) von Willebrand factor prekallikrein high molecular weight kininogen (HMWK) fibronectin antithrombin III heparin cofactor II protein C protein S protein Z Protein Z-related protease inhibitor (ZPI) plasminogen alpha 2-antiplasmin tissue plasminogen activator (tPA) urokinase plasminogen activator inhibitor-1 (PAI1) plasminogen activator inhibitor-2

Activates II: forms prothrombinase complex with factor V Activates IX Activates factor XI and prekallikrein Crosslinks fibrin Binds to VIII, mediates platelet adhesion Activates XII and prekallikrein; cleaves HMWK Supports reciprocal activation of XII, XI, and prekallikrein Mediates cell adhesion Inhibits IIa, Xa, and other proteases; Inhibits IIa, cofactor for heparin and dermatan sulfate ("minor antithrombin") Inactivates Va and VIIIa Cofactor for activated protein C (APC, inactive when bound to C4bbinding protein) Mediates thrombin adhesion to phospholipids and stimulates degradation of factor X by ZPI Degrades factors X (in presence of protein Z) and XI (independently) Converts to plasmin, lyses fibrin and other proteins Inhibits plasmin Activates plasminogen Activates plasminogen Inactivates tPA & urokinase (endothelial PAI) Inactivates tPA & urokinase (placental PAI)

Other substances that might participate in the coagulation cascade are present also in this table: Protein C protein S
Protein C and protein S are cofactors that inactivate the clotting factors so they help in keeping the blood in the fluid state and once there is an abnormal deficiency of these (protein S , protein C and antithrombin 3 ) we will expect a higher liability toward clot formation or coagulation. So deficiency in these elements will lead to thrombosis.

anti-thrombin 3 high molecular weight kininogen prekallikrein .

So these substances will aid in controlling the coagulation cascade. tpa (tissue plasminogen activator) will activate plasminogen which participates in fibrinolysis of the blood clot. urokinase ; which activates plasminogen and aids in the hydrolysis of the fibrin clot.

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This a schematic diagram for the activation of the cascade, you can see the platelet surface. The green rectangle (in the pic) represent the activated co-factor 8 (VIIIa), this will help in the process of activation of factor 10 (X) in the presence of the active factor 9 (IX). Factor 9 (IX) will activate factor 10 (X) in the presence of co-factor 8 (VIII) and calcium then the activated factor 10 (Xa) in the presence of calcium and the activated cofactor 5 (Va) will activate factor 2 (II) which is prothrombin , the prothrombin will become activated and become thrombin . Thrombin will convert fibrinogen to fibrin. So it is just like a cascade; each enzyme get activated and then activates the next substrate or the next pro-enzyme .

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This diagram summarizes the all reactions. We have extrinsic pathway, intrinsic pathway and common pathway where the two pathways (extrinsic and intrinsic) join together. Now why we call them extrinsic and intrinsic? The extrinsic pathway is activated by something called tissue factor or thromboplastin which comes from the endothelial cells, these cells are not part of the blood so they are extrinsic to the blood and thats why we call it extrinsic pathway. So the tissue factor that initiates the coagulation in the extrinsic pathway is extrinsic to the blood. The intrinsic pathway is activated by the activated factor 12 (XIIa) which is part of the blood so we call it intrinsic pathway. Now injury is not always necessary as an initiation factor; if the endothelial cells become malfunctioned due to one reason or another, this also might lead to production of tissue factor which will activate the extrinsic pathway.
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Coagulation cascade
1. Damaged cells (extrinsic pathway) display a surface protein (tissue factor: TF) that binds to activated Factor 7 (TF-7) to cleave: Factor 10 2. Factor 10 binds to receptors of Factor 5 and activates it forming (prothrombinase) that converts prothrombin (also known as Factor II) to thrombin 3. Thrombin proteolytically cleave fibrinogen (Factor I) to fibrin. 4. Factor 13 forms covalent bonds between the soluble fibrin molecules converting them into an insoluble meshwork the clot Factor 13 will make cross linkage of linking between the fibrin to make the blood clotty.

``These things are very easy to forget ,,, you will take it in the clinical ,, so just know the basics only,, just you know the idea ,, ok??!!!``
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 The extrinsic pathway starts by the activation of tissue factor, the tissue factor will be combined with factor 7 (VII). Tissue factor and factor (VIIa) compound with each other, this compound will inter to the common pathway. The common pathway will start by the activation of factor 10 (X). This compound (tissue factor + VIIa) will activate also factor 9 (IX), so the extrinsic pathway might lead to the activation of the intrinsic pathway through this series. So the intrinsic pathway not always activated from the start; the extrinsic pathway will activate indirectly the intrinsic pathway. The activate factor 10 (Xa), in the presence of the activate factor 5 (Va) will convert prothrombin to thrombin.

In the intrinsic pathway we dont need a tissue factor. If we put the blood or if the blood touches any surface other than the epithelium by glass or something this contact will activate the factor 12. Once the activation happens the whole stage will follow. Factor 12 activated, then this affects factor 11, This will activate factor 9, in the presence of factor 8, will activate factor 10 so the extrinsic and intrinsic.

Amplifying the Clotting Process

The TF-7 complex & factor 11 activate Factor 9. Factor 9 binds to factor 8, a protein that circulates in the blood stabilized by another protein (vWF). The complex of factors 9-8-vWF activates more factors: 5,10

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 A patient with an abnormal bleeding tendency, easily loosing his blood from nose, skin, into the joints, what are the causes for such a case? What are the causes for bleeding? Trauma Pathological diseases that are responsible for that bleeding? in general? Leukemia Malignancies in blood cells in children. Deficiency in any of the factors will lead to bleeding tendency o If one factor is missing, can we tell that if it belongs to intrinsic or extrinsic? Yes we can. Hemophilia

we have two types of tests: 1- Prothrombin time (PT): (Normal time from 11 to 13 seconds) It measures the extrinsic pathway 2- Partial thromboplastin time (PTT): (Normal up to 30, 31 or 35 seconds) It measures the intrinsic pathway They both are tests in the lab, and they are used to measure the time and speed for the blood to be clotted.

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The prothrombin time (PT)

its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) are measures of the extrinsic pathway of coagulation. This test is also called "ProTime INR" and "INR PT". They are used to determine the clotting tendency of blood, in the measure of warfarin dosage, liver damage, and vitamin K status. PT measures factorsI, II, V, VII, and X. It is used in conjunction with the activated partial thromboplastin time (aPTT) which measures the intrinsic pathway.(Wikipedia)

Partial thromboplastin time (PTT) is a blood test that looks

at how long it takes for blood to clot. It can help tell if you have bleeding or clotting problems. (newyork times)

hemophilia A factor 8- mainly :

PT = normal.

PTT = not normal because of missing in the pathway so activation of factor 10 is not going to happen.

Haemophilia
is a group of hereditary genetic disorders that impair the body's ability to control blood clotting or coagulation, which is used to stop bleeding when a blood vessel is broken. A (clotting factor VIII deficiency) is the most common form of the disorder, present in about 1 in 5,000 10,000 male births. Haemophilia B (factor IX deficiency) occurs in around 1 in about 20,00034,000 male births. Like most recessive sex-linked, X chromosome disorders, haemophilia is more likely to occur in males than females. This is because females have two X chromosomes while males have only one, so the defective gene is guaranteed to manifest in any male who carries it(Wikipedia)

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Vitamin K:
Some of the factors are vitamin K-dependent; need it for their synthesis plus its needed to function properly. These factors are (1972) = factors 10, 9, 7 and 2 If we have vitamin k deficiency, it will result in more bleeding tendency, because these factors are not going to function properly. Vitamin K is a cofactor needed for the synthesis (in the liver) of factors II (prothrombin), VII, IX, and X, proteins C and S. Deficiency of Vitamin K predisposes to bleeding. Conversely, blocking the action of vitamin K helps to prevent inappropriate clotting.

Warfarin is an effective vitamin K antagonist Warfarin is an anti-coagulant, it inhibits vitamin k from doing its function in relation to these factors, and it blocks the binding sites between factors and vitamin k so increasing the ability to bleeding. The test for warfarin function is the PT TFPI secreted by EC inactivating F.Xa and TF-VIIa complexes.

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I.N.R -international normalized ratio-:

PT of the patient / PT for a group of controls PT for a group controls: the average for PT test measures for a group of normal people. Patients with foreign body in their body we give them warfarin, we want the effect to be in many pathways to prevent coagulation and maintain the state of blood and prevent thrombosis. PT normal / PT control = 1 Now in the last case I want the PT to be prolonged so the therapeutic treatment ratio of INR must be (1.5 - 2.5), in this case we want the PT to be 4 times more than normal (PT = 13*4).

Actions of Thrombin:
Conversion of fibrinogen to fibrin. Activation of factor V. Activation of factor VIII. Activation of factor XIII. Activation of protein C. Activation of platelets. Activation of endothelial cells. Activation of monocytes

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Controlling Coagulation Cascade

Antithrombin III inactivates prothrombin, F.9 & F.10 Heparin binds to and enhances antithrombin III. -- We measure it by PTT.

Protein C and its cofactor Protein S (vitamin K-dependent) Together inhibit thrombin formation by inactivating cofactors Va & VIIIa Inherited deficiency (mutations) of Protein C or Protein S thrombophilia

TFPI secreted by EC inactivating F.Xa and TF-VIIa complexes.

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Also we control it by what's we call a fibrinolytic cascade which limit the size of final clot The doctor said I will just read them- The cleavage of Plasminogen by factor XII or Plasminogen activators especially the tissue plasminogen activators will activate the plasmin (Plasminogen become Plasmin) which breaks down fibrin result's in what we call fibrin split product or fibrin degradation product. Normally if we have free Plasmin it is in activated by binding ta 2 Antiplasmin so that any excess in the Plasmin does not lysis clot elsewhere in the body. Endothelial cells release Plasminogen activator inhibitors. Streptokinase can cleave Plasminogen.

Now if anybody has myocardial infarction, within the first hour what is the treatment of choice?!?! We need to dissolve the clot (we have athrombous in myocardial infarction within the coronary arteries so the main treatment to dissolve this thrombous as soon as possible) by streptokinase which produce from abacteria and there is something better which is TPA (tissue Plasminogen activator) because it is not producing hyper sensitivity so when we have a myocardial infarction we give thrombolytic agent like streptokinase or TPA.

Thrombosis
represents a pathologic state in which there is a formation of intra vascular solid mass which is the blood clot in uninjured blood vessel or after a relatively minor injury. Here we talk about pathology so endothelium is not injured or is minorly injured in minor injury in normal person this will not be a problem. In disease some of the disease patient any minor trauma this is a catastrophe. In the clinical they will ask you a question! What are the causes of thrombosis and you always answer in smart way there are three causes the called a (Virchow's triad): 1. endothelial injury. 2. Stasis or turbulence of blood flow. 3. Blood hyper coagulabilty. The causes of thrombosis as a result of one of these factors or all of them together called (Virchow's Triad) Virchow's is a person.
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They have endothelial injury (Hay Ma3rofeh Lesh!!), Once there is export to the matrix this will activate platelets. We have the stasis or turbulence of blood flow. And the last one is the blood hyper coagulability. From those factors mainly endothelial injury will participate in thrombus formation. This one will lead to this on, and this one will lead to this one and all of them will lead to thrombosis.

The first one endothelial injury is the commonest cause of thrombus formation and it is mainly in the site of high blood flow because in these areas in the arteries in heart the blood is flowing strongly so we need a sort of strong thrombus to happen there in order to stay there. So endothelial injury is the strongest activator of thrombosis. Injury in endothelial cells can be caused by endothelial injury, The endocardium is the lining of inner site of the heart, because it's inside the heart so it's the least blood supply or least oxygenated area. In the liver where is the most lease oxygenated area?? Central hepatocyte. They are present around the central venule in the central lobule.

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Now in the heart the endocardim is the least blood supply, why?? Because the coronary artery in the pericardium (outside) by logic. Now in myocardial infarction what is going to happen?? Death of cardiac muscle, so always ischemia starts with the endocardium because its the furthest way. Any destruction any ischemia of these lining will lead to injury fibrosis which is not normal and not smooth and this will activate thrombosis. Valvulitis, Vasculaitis any inflammation in the blood vessel in endocardium this will lead to enocardial or endothelial injury and thrombosis vaiability. Traumatic and inflammatory condition like vasculaitis, bacterial infection, and viral infection all these things will lead to endothelial injury. Atherosclerosis once it's ulcerated it's a rough surface so this will activate the platelets and thrombus formation.

Dysfunctional endothelium, we don't need always an injury for such things to happen sometimes the endothelium will be malfunctioning. Which result in alteration in dynamic balance of the pro-thrombotic and the anti-thrombotic effects, this caused by: --Hemodynamic stresses like hyper tension, turbulent blood flow over scarred valves, or bacterial endotoxins. All these things can lead to malfunctioning of the endocadium without an injury, I mean the surface will be just smooth not denuded and not ulcerated but still the area viable for thrombosis. - - A condition called a homocystinuria. - - A condition called hyper cholesterolemia. - - Products absorbed from cigarette smoke - - Radiation

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All these things can lead to alteration the function of the endothelial cells so these cells will produce more thrombotic factors. Result of endothelial injury we take it in the previous lectures: o o o o Exposure of sub endothelial collagen Adherence platelet Release of tissue factor Release of tissue factor

Alteration in Blood Flow:

Turbulence leads to EC injury or dysfunction, and stasis (a major contributor of venous thrombosis), what is the meaning of the stasis?? The blood is not flowing in the normal rate. Usually it happens in the venous side. - Stasis and turbulence lead to: - Disruption of laminar flow (blood normally flow usually platelets the cell in the central of the flow, between them in the periphery adjacent to the wall just the plasma) once there is a stasis this laminar flow will be what?? Disturb, so platelets will getting into contact with the endothelium.
- Prevent dilution of activated clotting factors by fresh-flowing blood (there will

be no blood just wash out all the activated clotting factor this would also help to produce thrombosis) - Decrease inflow of coagulation factor inhibitors and permit the buildup of thrombi Help activate endothelial cells leading to thrombosis and leukocyte adhesion the stasis mainly is a venous thing, and usually the thrombosis location will be in the venous side.

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Clinical Conditions Causing (Turbulence and Stasis):

- Ulcerated atherosclerotic plaques, turbulence in the flow. So this will this will lead to thrombus formation. - Abnormal aortic and arterial dilations (aneurysms), once there is a dilatation of the heart like a cyclic dilation this is called aneurysms, this is an abnormal pocket this will help in altering the blood flow. This one help in thrombus formation.

- Acute myocardial infarction (aneurysm), once the wall is fibrous it will be weaken, this weaken in the presence of intraventrecular blood pressure this will push the weak area outside so this will help to form aneurysm of abnormal dilatation of the heart.

- Atrial fibrillation & atrial dilation that caused by mitral valve stenosis (rheumatic heart disease), fibrillation like this, this will lead that the blood will be stagnant (this is stasis), this will aid in thrombus formation.

- Hyperviscosity syndromes (polycythemia), any thick fluid, the flow will be not that quite as the thin fluid.

- Sickle cell anemia (not important)

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Hypercoagulability
The third factor is hypercoagulabilty primary genetic disease and acquired. - Primary (Genetic) Causes: mutation in factor V gene & prothrombin gene are most common - Antithrombin III deficiency - Protein C deficiency - Protein S deficiency - Defects in fibrinolysis

These things are genetic and usually the patient is young below 15,14 presented with thrombosis. Acquired: - bed rest and immobilization what's the meaning of immobilization?? if patient had open heart surgery, this patient will be in the bed (bedridden). So once there is bedridden what happened to the blood of the legs?? Stasis, why stasis?? No muscle contraction, muscle contraction will direct the blood toward the heart, so once there is a bed rest, the blood is not moving, so this will lead to stagnant blood flow, this will lead to stasis, and this will lead to thrombus formation. As I Said before they don't work separately, all of them works at the same time, so bed rest should be in stasis but it mentioned here, just all thing are happening together. - Myocardial infarction, we talked about it.

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- Tissue damage.

- Cancer in diffuse metastatic cancer, cancer cell will produce prothrombatic material; these materials will help in reducing or accelerating thrombus formation.

- Artificial valve, because there are abnormal rough surface relatively so we need warfare here to prevent thrombosis. - Some syndrome, the most common one that you will take in the clinical antiphopholipid syndrome or anticardio lipid syndrome, So We have primary and secondary, secondary is in what we called (SLE), all these diseases you will hear about later on.
- Polycythemia (highviscosity)

- sickle cell disease, because the cells are viable to obstructing the blood vessel, this will lead to stasis. - Oral contraceptives also they are thrombatic agent. ** antiphospholipid syndrome presentation of multiple thrombosis multiple abortion or miscarriages, presentation of inflammation, presentation of infraction, in any young patient suspect a genetic disease either deficiency or this syndrome.

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Once the thrombosis form we have two types: venous or arterial. In arterial thrombi usually endothelial damage, atherosclerosis, MI, rheumatic heart diseases. Venous thrombi stasis in veins. Growth: usually the clot is attached vocally to the blood vessel walls, once there is aggregation of a platelet the direction of aggregation in the artery will be against the flow, so direction going to this way the clot start in this way, and grows opposite the blood flow direction IE toward the heart side. In venous it's with the blood flow IE toward the heart. so both are artery and vein the side of growth of the clot is toward the heart, but it's against the flow in the artery and with the flow in the vein. lines of zahn, thrombosis is lines contain platelet, fibrin and RBC's

Pale line is formed by platelet and fibrin. red line is formed by RBC's.
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** (he continued reading the table) ..

Fate of the thrombus

propagation: thrombus will increase in size. - Embolization: once there is increase in the size, that means the point of attachment of this point propagation here, so this distal point is not attached to the wall, so this is like cap fragmented, and go to somewhere else (migration of thrombus in the blood vessel) - Dissolution: by fibrinolysis - organization, thrombus can become organized, fiberosed, and recanalized.

Thrombosis with organization of the thrombus and recanalization:

Once there is chronic obstruction there are small blood vessel within the thrombus that will act as recanalized the thrombus, so these are the fate of thrombus

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Once there is chronic obstruction there are small blood vessel within the thrombus that will act as recanalized the thrombus, so these are the fate of thrombus This is blood vessel, this is an atherosclerotic plaque. once there is an injury a thrombus will form in top, so this is thrombus on top of atheromatous plaque, these things represent the recanalization small blood vessel form in this thrombus.

Complications of Thrombi:
- Occlusion of blood vessels Veins: Congestion and edema distal to obstruction and embolization Arteries: Ischemia and infarcts in areas supplied by the vessel, ischemia because myocardial infarction once there is inclusion in artery this mean there is infarction, all of them are secondary to obstruction in the artery. - Embolization: Once there is embolization of the lung is a serious problem.

The end
Done by : Hamza Rababah and Ahmad Alhajjeah

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