SECONDARY HEMOSTASIS

Secondary Hemostasis

 is defined as the formation of insoluble, cross-linked fibrin by activated

coagulation factors, specifically thrombin.
 Fibrin stabilizes the primary platelet plug, particularly in larger blood vessels.
where the platelet plug is insufficient alone to stop hemorrhage.

Primary and Secondary Hemostasis

The Intrinsic and Extrinsic Coagulation Pathway
Intrinsic Coagulation Pathway
Activated in vivo by contact of certain coagulation proteins with subendothelial
connective tissue, which sets the secondary hemostatic mechanism into motion.
Extrinsic Coagulation Pathway
In contrast, is initiated with the release of tissue factor from injured vessel
endothelial cells and subendothelial into the vessel lumen.
Role of Coagulation in Hemostasis

 Coagulation is a process whereby, on vessel injury, plasma proteins, tissue factors, and
calcium interact on the surface of platelets to form fibrin clot. (platelet-fibrin clot)
 A series of biochemical reactions referred to as the coagulation cascade leads to the
formation of a stable fibrin clot.
 The goal of secondary hemostasis is to generate sufficient amount of thrombin to
convert soluble fibrinogen to insoluble fibrin.
Coagulation

 Blood coagulation occurs on cell surface phospholipid membranes provided by

subendothelial tissue that is exposed when vessel endothelial is injured and by activated
platelets
 Clotting factors bind to phospholipid (PF3) surface until enzyme, substrate and cofactor
is formed.
 Activated platelets participate in coagulation where they express receptors for factors
VIII, Va
 Final product is a fibrin mesh or clot which completely stops bleeding.
 Slow contraction and lysis of the clot occurs.
 Coagulum

is the physical manifestation of fibrin formation which represents the end result of a series of
reactions of coagulation factors (plasma proteins) a.k.a. clotting factors, plasma factors, pro-
coagulants, coagulation proteins.

Clot

It is composed of platelet plug formed in primary hemostasis and fibrin

formed in secondary hemostasis.

Nomenclature of Procoagulants

 Plasma transports at least 16 procoagulants, also called coagulation factors.

 Nearly all are glycoproteins synthesized in the liver, although monocytes, ECs,
and megakaryocytes produce a few.
 Eight are enzymes that circulate in an inactive form called zymogens.
 Others are cofactors that bind, stabilize, and enhance the activity of their
respective enzymes.
Classification and Function of Procoagulants

 The plasma procoagulants may be serine proteases or cofactors, except for factor
XIII, which is a transglutaminase .
 29 Serine proteases are proteolytic enzymes of the trypsin family and include the
procoagulants thrombin (factor IIa); factors VIIa, IXa, Xa, XIa, and XIIa; and pre-K.3
Substrate
substance on which enzyme acts (ex: Fibrinogen)
Zymogen/ enzyme precursor
they are zymogens having no biologic activity until converted by enzymes to active forms
( ex: II, VII, IX, X, XI, XII, PK)
Cofactor
component that aids in the activation of zymogen to active enzyme (ex: III, V, VIII,
HMWK)

Vitamin K–Dependent Prothrombin Group

 Substrate Fibrinogen, V, VIII, XI, XIII IX, X X Prothrombin IX XI XI Prothrombin (factor

II), factors VII, IX, and X and the regulatory proteins protein C, protein S, and
protein Z are vitamin K–dependent (Table 37-7).
 These are named the prothrombin group because of their structural resemblance
to prothrombin. All seven proteins have 10 to 12 glutamic acid units near their
amino termini.

Hemorrhagic Disorders
Hemorrhage

 is severe bleeding that requires physical intervention.

  Hemorrhage may be localized or general, acquired or con-genital.

Localized Versus Generalized Hemorrhage

Localized Hemorrhage

 Bleeding from a single location commonly indicates injury, infection, tumor, or an

isolated blood vessel defect.
 Localized bleeding seldom implies a blood vessel defect, a qualitative
platelet defect, a reduced platelet count (thrombocytopenia), or a
coagulation factor deficiency.
Generalized Hemorrhage

 Bleeding from multiple sites, spontaneous and recurring bleeds, or a

hemorrhage that requires physical intervention and transfusions
 Generalized bleeding is potential evidence for a disorder of primary
hemostasis such as blood vessel defects, platelet defects, or
thrombocytopenia, or secondary hemostasis characterized by single or
multiple coagulation factor deficiencies.
Mucocutaneous Versus Anatomic Hemorrhage
Mucocutaneous hemorrhage

 May appear as petechiae, pinpoint hemorrhages into the skin, purpura,

purple lesions of the skin greater than 3 mm caused by extravasated
(seeping) red blood cells (RBCs); or ecchymoses (bruises) greater than 1 cm
typically seen after trauma
Anatomic (soft tissue) hemorrhage

 is seen in acquired or congenital defects in secondary hemostasis, or

plasma coagulation factor deficiencies (coagulopathies).
Acquired Versus Congenital Bleeding Disorders
Congenital hemorrhagic disorders

 are uncommon, occurring in fewer than 1 per 100 people, and are usually
diagnosed in infancy or during the first years of life.
 Congenital bleeding disorders lead to repeat hemorrhages that may be
spontaneous or may occur following minor injury or in unexpected
locations, such as joints, body cavities, retinal veins and arteries, or the
central nervous system.
 The most common congenital deficiencies are VWD, factor VIII and IX
deficiencies (hemophilia A and B), and platelet function disorders. Inherited
deficiencies of fibrinogen, prothrombin, and factors V, VII, X, XI, and XIII are
rare.
Acute Coagulopathy of Trauma-Shock

 accounts for most fatal hemorrhage, and 3000 to 4000 of these deaths are
preventable. Coagulopathy is def ined as any hemostasis deficiency, and ACOTS is
triggered by the combination of injury-related acute inflammation, platelet
activation, tissue factor release, hypothermia, acidosis, and hypoperfusion (poor
 distribution of blood to tissues caused by low blood pressure), all of which are
elements of systemic shock

Liver Disease Coagulopathy

 The bleeding associated with liver disease may be localized or generalized,

mucocutaneous or anatomic.
Procoagulant Deficiency in Liver Disease
o The liver produces nearly all of the plasma coagulation factors and
regulatory proteins.
Platelet Abnormalities in Liver Disease
o Platelet counts of less than 150,000/mL may result from sequestration and
shortened platelet survival associated with portal hypertension and resultant
hepatosplenomegaly.
Disseminated Intravascular Coagulation in Liver Disease
o Chronic or compensated DIC is a significant complication of liver disease
that is caused by decreased liver production of regulatory antithrombin,
protein C, or protein S and by the release of activated procoagulants from
degenerating liver cells.
Chronic Renal Failure and Hemorrhage

 Chronic renal failure of any cause is often associated with platelet dysfunction and
mild to moderate mucocutaneous bleeding.
Nephrotic Syndrome and Hemorrhage
o Nephrotic syndrome is a state of increased glomerular permeability
associated with a variety of conditions, such as chronic glomerulonephritis,
diabetic glomerulosclerosis, systemic lupus erythematosus, amyloidosis, and
renal vein thrombosis.
Vitamin K Deficiency and Hemorrhage

 Vitamin K is ubiquitous in foods, especially green leafy vegetables, and the daily
requirement is small, so pure dietary deficiency is rare.
Hemorrhagic Disease of the Newborn
o Caused by Vitamin K Deficiency Because of their sterile intestines and the
minimal concentration of vitamin K in human milk, newborns are
constitutionally vitamin K deficient.
Vitamin K Antagonists: Coumadin
o The g-carboxylation cycle of coagulation factors is interrupted by coumarin-
type oral anticoagulants such as Coumadin (warfarin) that disrupt the
vitamin K epoxide reductase and vitamin K quinone reductase reactions
Autoanti-VIII Inhibitor and Acquired Hemophilia

 Acquired autoantibodies that specifically inhibit factors II (prothrombin), V, VIII, IX,

and XIII and VWF have been described in nonhemophilic patients.
 Patients who develop an autoantibody to factor VIII, which is diagnostic of
acquired hemophilia, are frequently older than age 60 and have no apparent
underlying disease.
 Acquired hemophilia is occasionally associated with rheumatoid arthritis,
inflammatory bowel disease, systemic lupus erythematosus, or lymphoproliferative
disease.
Acquired von Willebrand Disease

 Acquired VWF deficiency, with symptoms similar to those of congenital VWD, has
been described in association with hypothyroidism; autoimmune, lymphoproliferative,
and myeloproliferative disorders; benign monoclonal gammopathies; Wilms tumor;
intestinal angiodysplasia; congenital heart disease; pesticide exposure; and
hemolytic uremic syndrome.
Hemophilia A (Factor VIII Deficiency)

 The hemophilias are congenital single-factor deficiencies marked by anatomic soft

tissue bleeding.
 Second to VWD in prevalence among congenital bleeding disorders, hemophilias
occur in 1 in 10,000 individuals. Of those affected, 85% are deficient in factor VIII,
14% are deficient in factor IX, and 1% are deficient in factor XI or one of the
other coagulation factors, such as factor II (prothrombin), V, VII, X, or XIII.
 Congenital deficiency of factor VIII is called classic hemophilia or hemophilia A.

Hemophilia B (Factor IX Deficiency)

 Hemophilia B, also called Christmas disease, totals approximately 14% of

hemophilia cases in the United States, although its incidence in India nearly equals
that of hemophilia A.
  Hemophilia B is caused by 6 of factor IX, one of the vitamin K–dependent serine
proteases. Factor IX is a substrate for both factors XIa and VIIa because it is
cleaved by either to form dimeric factor IXa.
Hemophilia C (Rosenthal Syndrome, Factor XI Deficiency)

 Factor XI deficiency is an autosomal dominant hemophilia with mild to moderate

bleeding symptoms.
 More than half of the cases have been described in Ashkenazi Jews, but
individuals of any ethnic group may be affected.

Fibrinolysis
Fibrinolysis

 Fibrinolysis, the final stage of coagulation (Figure 37-21), begins a few hours after
fibrin polymerization and cross-linking.
 Two activators of fibrinolysis, TPA and UPA, are released in response to
inflammation and coagulation. Fibrinolytic proteins assemble on fibrin during
clotting.
 Plasminogen, plasmin, TPA, UPA, and PAI-1 become incorporated into the fibrin
clot as they bind to lysine through their “kringle” loops, thereby concentrating and
localizing them to the fibrin clot.
 Fibrinolysis is the systematic, accelerating hydrolysis of fibrin by bound plasmin.

Proteins of the Fibrinolysis Pathway

Plasminogen

 is a 92,000 Dalton plasma zymogen produced by the liver

 It is a single-chain protein possessing five glycosylated loops termed kringles.
Kringles -enable plasminogen, along with activators TPA and UPA, to bind
fibrin lysine molecules during polymerization .
Plasmin

 is a serine protease that systematically digests fibrin polymer by the hydrolysis of

arginine-related and lysine-related peptide bonds.
  Bound plasmin digests clots and restores blood vessel patency. Its localization to
fibrin through lysine binding prevents systemic activity.
 Free plasmin is capable of digesting plasma fibrinogen, factor V, factor VIII, and
fibronectin, causing a potentially fatal primary fibrinolysis.

Plasminogen Activation
Tissue Plasminogen Activator (TPA)
 ECs secrete TPA, which hydrolyzes fibrin-bound plasminogen and initiates
fibrinolysis.
Urokinase Plasminogen Activator (UPA)

 Urinary tract epithelial cells, monocytes, and macrophages secrete another

intrinsic plasminogen activator called urokinase plasminogen activator.
 UPA has only one kringle region, does not bind firmly to fibrin, and has a
relatively minor physiologic effect.
Control of Fibrinolysis
Plasminogen Activator Inhibitor 1 (PAI-1)

 PAI-1 is the principal inhibitor of plasminogen activation, inactivating both

TPA and UPA and thus preventing them from converting plasminogen to the
fibrinolytic enzyme plasmin.
a2-Antiplasmin

 a2-Antiplasmin (AP) is synthesized in the liver and is the primary inhibitor

of free plasmin. AP is a serine protease inhibitor with the unique
characteristic of both N- and C-terminal extensions.
Thrombin-Activatable Fibrinolysis Inhibitor

 TAFI is a plasma procarboxypeptidase synthesized in the liver that becomes

activated by the thrombin-thrombomodulin complex.
Fibrin Degradation Products and D-Dimer
Plasmin cleaves fibrin and produces a series of identifiable f ibrin fragments: X, Y,
D, E, and D-D.