1. Normal coagulation
2. Tests of coagulation
3. Hemorrhagic and thrombotic
disorders
• Primary hemostasis
Platelet plug formation
Adhesion and aggregation
• Secondary hemostasis
Coag pathway, form fibrin
• Tertiary hemostasis
– Crosslinking of fibrin and fibrinolysis
COAGULATION
z A complicated process that must prevent
both excessive bleeding and excessive
clot formation
platelet
vWF
Damaged endothelium
Alpha granule
Delta granule
= GP1b/V/IX
= GPIIb/IIIaX
platelet
vWF
Primary Hemostasis
Aggregation
Adhesion
Damaged endothelium
understanding this process will help us
understand some diseases
www.azer.com/.../magazine/73_folder/ 73_photos/73_306.jpg
THROMBOPHILIA BLEEDING
Enzymes that, when activated, catalyze activation of sequential
steps that lead to fibrin formation
Bowen, D J Mol Pathol 2002;55:127-144
Copyright ©2002 BMJ Publishing Group Ltd. 2002 BMJ Publishing Group Ltd.
FVIII and V cofactors
Thrombin
Factor XIII Factor XIIIa
Inhibiting fibrinolysis
1. Alpha two antiplasmin inhibits plasmin
2. PAI inhibits plasminogen
3. TAFI (thrombin activatable fibrinolysis inhibitor)
Inhibits binding of plasminogen and TPA to fibrin
Noble
fibrinolysi
s
D D
fibrin D-dimers
split In pulmonary embolism
products
E
Fragment E
Anticoagulation
• Protein C
Thrombomudulin binds to thrombin to activate protein C; with
its carrier, protein S, APC inhibits FV and FVIII
• Antithrombin
Liver-produced AT binds to heparin and inhibits conversion of II
to IIa; also inhibits Xa action
Protein C, S
• 2. bleeding time
-worthless test, used to tell if patient might bleed at surgery
-Use blade on pt’s forearm, blot blood with filter paper
time w stopwatch to see when bleeding stops
-Each lab has different normals,
-Does not predict functional bleeding. If you have a
normal or abnormal bleeding time, it will not predict
whether you bleed
-PFA is better
Activated Partial Thromboplastin Time
(aPTT) <40 seconds
ISI
⎛ Patient PT ⎞
INR = ⎜⎜ ⎟⎟
⎝ Normal mean PT ⎠
ISI – International Sensitivity Index; related to
amount of tissue factor in reagent
INR--Developed to compensate for reagent
differences
Normal PT, aPTT, platelets
• Mild vWD
• Uremia
• Surgery
• Inherited platelet D/O
• Vascular D/O
• Fibrinolytic D/O
• XIII deficiency
• Dysfibrinogenemia
• Mild factor deficiency
(VIII, IX, XI)
PT, normal aPTT, normal platelets
• F VII deficiency or
inhibitor
• Coumadin
• Liver disease
• dysfibrinogenemia
Normal PT, aPTT, normal platelets
• Heparin effect
• vWD
• VIII, IX, XI
deficiency
• inhibitor
• Lupus anticoagulant
PT, aPTT, and normal platelets
Common
• Coumadin
• Heparin
• Liver disease
• Vitamin K deficiency
• DIC
• Dysfibrinogenemia
• Primary fibrinolysis
PT, aPTT,and platelets
Common
• DIC
• Liver disease
• Heparin with
thrombocytopenia
Nl PT, Nl aPTT, platelets
Common
• Destruction
• Sequestration
• Decreased
production
• Bernard-Soulier
Nl PT, Nl aPTT, platelets
Myeloproliferative disorders
Additional tests
• Thrombin time
• Reptilase time
• Mixing studies
• Platelet aggregation studies
Thrombin time
Exogenous thrombin
+ Measure the time to clot
Patient’s platelet-poor plasma
Perform PT or aPTT
-Initial
-At 60 minutes
Shine light
Through platelets Aggregated platelets
Add
Agent
50
Second phase
of aggregation
(more ADP release
& TXA2 release)
0 3
Time (min)
• Petechiae • Hematoma\hemarthrosis
• menorrhagia • Large bruises
• Female • Male
• No family history • + family history
• vWD, BS dz • Coag disorders
• Thrombocytopenia
Congenital
• Bernard-Soulier Disorder
• Glanzmann thrombasthenia
• May Hegglin
Bernard-Soulier
platelet
vWF
LGPIb Ladhesion,
bleeding occurs
Bernard Soulier Disorder
Glanzmann thrombasthenia
Nl adhesion
VWF
Glanzmann thrombasthemia
May Hegglin Anomaly
mutated myosin heavy chain 9
Dohle body (RER) + giant plt
Little bleeding
Autosomal dominant
High yield board fact
• Giant Platelets
• ITP, May Hegglin, gray platelet
syndrome, Bernard Soulier, Montreal plt
syndrome,
• Mediteranean macrothromocytosis.
• Sebastian, Fechner, Epstein, and Alport
syndromes
Storage Pool Deficiency
always on boards, never in clinical
practice
pathology.mc.duke.edu/coag/ images/29_rgb.jp
vWD Type I
• Type 2b
• large multimers
• ↑affinity HMW multimers for GP1b
• leads to increase clearance of vWF
• K RIPA, No DDAVP
• Type 3
• Autosomal recessive, most AD
• Severe marked deficiency
• Absence of vWF, F8 also low
• But may have nl coag parameters
• VWF too low for multimers
• No DDAVP
vWD multimers analysis
RIPA
vWF 2M and 2N
• Type 2M
• Defect in GP 1b binding
• vWF made but doesn’t work, vWFRco
• Sometimes nl—RIPA, multimers, vWF Ag, F8
• Suspect when vwf:Rcof < vwf Ag
• Type 2N (Normandy)
• Defective F8 binding
• Vwf decreased affinity for F8
• Hemophilia-like (but AR), women w low F8, think of this dz
• F8 carriers
• -woman whos dad has hemophilia
• -mom of hemophiliac child Nl Dad XY, carrier mom XHX
• Afibrinogenemia
• Quantitative, AR
• mixing study corrects
• Dysfibrinogenemia
• AD, thrombophilic, qualitative
• Mixing study partial corrects-inhibitor
• Lab findings
• PT, PTT, TT, Lplt count, Lfibrinogen, LATIII, Lplasminogen
• ↓prot C, S, ATIII, α2antitrypsin,
• FDPs sensitive not specific.
• D-dimer specific,
• Protamine sulfate
TTP/HUS-- a board favorite
• Clinical manifestations: hemolytic anemia w schistocytes, Lplts, fever,
neural probs, renal dysfunction, abdominal pain
• Microthrombi in different organs
• TTP Big vWF multimers, cant cleave, shear RBC causing MAHA
• HUS normal vWF cleavage protease
•
• Tx
• TTP: FFP + steroids +Ivig + splenectomy., don’t give platelets
• HUS: supportive + antibiotics
• HUS + TTP are treated differently.
TTP
CD 61
THROMBOPHILIA BLEEDING
Thrombophilia
• Predisposition to thrombosis from familial or acquired
disorders of hemostasis
• Labs:
1.free protein S
2. total protein S
3. protein S activity (best test)
• Autosomal dominant
Antithrombin III deficiency
• Antithrombin binds to heparin to inhibit factors II and X.
• In ATIII deficiency, patient presents w ↓response to heparin
• Clinical features:
– Systemic Lupus Erythematosis (15-30% of cases)
– Venous thrombosis
– Peripheral arterial thrombosis
– Myocardial infarction
– Stroke or ischemic attacks (<55 years)
– Recurrent fetal loss
– Thrombocytopenia
• 1.PTT
• 5. β2 Glycoprotein I antibodies--immunoassay
tests
• 6. platelet neutralization procedure
PTT fails to correct w mixing study, but PTT
corrects when you add hexagonal phase
phosphatidyl ethanolamine
• Dx:
z Numerous assays; patient blood add heparin look for coagulation
• Tx:
• -Stop heparin/don’t give plts, no warfarin
• - thrombin inhibitors, monitored by PTT,
Homocysteine
• Sulfhydryl amino acid needed for the formation of cysteine and
methionine
• level associated with venous thrombosis/atherosclerosis
Homocysteinemia
• AR, lens dislocate, MR, peripheral neuropathy,
• sometimes folate ↓
• Dx:
• 1. serum levels
• 2. Methyl tetrahydrofolate reductase
• mutation 3. Mutation in CBS cysathionine
βsynthase
Board Questions/facts
• vWF made in Megas and endothelial cells
• Bernard Soulier
• vWF different subtypes/tests
• Platelet aggregation studies
• Differences b/t alpha and delta granules
• Storage pool disorders
• Differences b/t TTP and HUS
• Liver disease
QUESTIONS