Components of Hemostasis

• Primary Hemostasis (Platelets & vWF)

• Coagulation Cascade (Intrinsic & Extrinsic)

• Inhibitors of Coagulation (Natural & Acquired)
• Fibrinolytic System (Activators, Inhibitors &
Degradation products)
Activated partial thromboplastin time (aPTT)

Derives its name from use of a partial activated

Component like the phospholipid cephalin and
Negatively charged substance like kaolin for activation

Expressed in seconds with normal range (27-40’’)

Prolonged:
Heparin therapy
Presence of anticoagulant (lupus like)
Factor deficiency
Massive blood transfusion.
Liver disease
High dose coumadin anticoagulation
 Factor Inhibitors
The mixing study
The patient's serum is mixed with normal serum and the aPTT of
this mixture is measured. A 50:50 mixture will correct a factor
deficiency (only 30% activity is needed for a normal aPTT). In the
presence of an inhibitor, a 50:50 mix will not correct the abnormal
coagulation test. If inhibition found, additional tests with diluted
patient serum and normal serum will be applied and level of
inhibitor will be determined (Bethesda units) by the dilution activity

Factor VIII inhibitors

IgG mostly, Occur primarily in haemophilia A patients who have
received blood component transfusions. They develop a severe
coagulopathy that is very difficult to manage May occur in a
variety of unrelated conditions with a coagulopathy that is variable
and usually disappears spontaneously.
Inhibitors of coagulation and
fibrinolysis
 Half life (hrs) Chromosome Function

Protein C 4 2q13-14 Protease

(FV&FVIII)
Protein S 42 3p11.1-11.2 APC-cofactor
Thrombo modulin ND 20p11.2-cen Receptor for
Thrombin/Prot.C

Protein C receptor ND 20q11.2 Receptor for

prot.C/APC
Antithrombin 70 1q23-25 Protease inhibitor

TFPI ND 2q31-32.1 Protease inhibitor

Heparin Cofactor 60 22q11 Protease inhibitor

II
 Activation by
thrombin or FXa
 APC inactivates FVa
 FV-Leiden has Gln
instead of Arg at
506, which confer
APCR
 Protein C
pathway
sEPCR

APC FVIIIa
sEPCR

PC
T sEPCR
FVIIIa
FVa
T
TM PC APC FVa
EPCR EPCR
S
 History
• 1965 – Antithrombin (Egeberg)
• 1965 – dysfibrinogenemia (Beck)
• 1981 - Protein C (Griffin)
• 1984 - Protein S (Comp)
• 1993- APCR (Dahlback)
• 1994 – Factor V Leiden (Bertina)
• 1996 - PT G20210A mutation (Poort)
Large vessel - Death
Medium vessel - Respiratory
Failure
Small vessel- asymptomatic
repetition –
pulmonary
hypertension

Block

Embolus

Lysed / Extend
Organized

Thrombus
 40
35
30
of % 25
VTE 20 35%
among 15 26
%
autopsie 10
s 5
9
.4%
0
VTE PE Fatal PE
Accountsfor about 10% of deaths in hospitalised patients1
1.Lindblad B, et al. BMJ 1991;302:709–11
2. Dahl OE, Bergqvist D. Curr Opin Pulm Med 2002;8:394–7
Venous Thrombosis Makes News
in Washington
Surgeon General nominated VTE
Task Force
: Inherited
Common- )Factor V G1691A )Leiden
Prothrombin G20210A              
Increased levels of FVIII and              
Fibrinogen
Rare- Antithrombin deficiency 
Protein C deficiency               
Protein S deficiency               
Very rare- Dysfibrinogenemia 
Homozygous homocystinuria               
 

? Future risk factors

:Acquired
Trauma or surgery
Immobilization
Increasing age
Malignant disorders
Myeloproliferative disorders
Previous thrombosis
Pregnancy and puerperium
Use of contraceptives or HRT
Activated protein C resistance
Mild to moderate hyperhomocystinemia
Antiphospholipid syndrome
 ‫ב‪.‬א‪ .‬בת ‪ 46‬אושפזה עקב נפיחות וכאבים ברגל‪ .‬באמצעות פלבוגרפיה‬
‫אובחנה פקקת (‪ )DVT‬והוחל טיפול בהפרין וקומדין‪ .‬במהלך האישפוז‬
‫תלונות על קוצר נשימה‪ ,‬אובחן תסחיף ראתי‪ .‬אבחנה‪APS :‬‬
‫כ‪ 10-‬חדשים לאחר מכן אושפזה לניתוח אלקטיבי‪ ,‬הופסק קומדין‪,‬‬
‫יומיים לאחר הניתוח – קוצר נשימה ‪ -‬תסחיף ראתי‪.‬‬
‫‪ 5‬שנים לאחר‪ ,‬תלונות על העדר תחושה‪ ,‬בבדיקת ‪ MRI‬נמצאו מוקדים‬
‫במוח‪.‬‬
‫‪B.E‬‬ ‫‪- Laboratory findings‬‬

‫‪Coagulation‬‬
‫‪aPTT‬‬ ‫)‪71” (C. 27-38‬‬
‫‪aPTT mixed with plasma‬‬ ‫)”‪54” (C. 32‬‬
‫‪CAI‬‬ ‫)‪34 (C < 15‬‬
‫‪RVVT‬‬ ‫)‪2.9 (C < 1.3‬‬
‫‪RVVT confirm‬‬ ‫‪1.8‬‬
‫‪TTI‬‬ ‫)‪2.14 (C < 1.25‬‬
‫‪APCR‬‬ ‫) ‪1.45 (C > 2‬‬
‫‪Factor V Leiden‬‬ ‫‪normal‬‬

‫‪Immunology‬‬
‫‪anticardiolipin‬‬ ‫‪75u/ml‬‬ ‫)‪(C < 15‬‬
‫‪anti-nuclear ab.‬‬ ‫)‪417 u/ml (C < 200‬‬
‫‪anti-DNA‬‬ ‫)‪190 u/ml (C < 50‬‬
 Endothelial cell mediated: injury to
EC, receptor induction, increased TF
expression, induction of apoptosis
 Protein C pathway related: aPL binds
PC&S inhibition of PC activation,
acquired APCR
 Inhibition of heparin-AT complexes
 Cross reaction with OX-LDL
 Increase PAI-1
 Platelet activation
 Clinical criteria
1.Vascular thrombosis )one or more ATE or VTE)
2. Pregnancy morbidity
a. one or more IUFD >10th week
b. one or more premature birth, preeclampsia,
placental insufficiency, abruption, IUGR
c. 3 or more early )10th week) abortions,) >2 late)
 Laboratory criteria
1. Anti CL Ab )IgG/M), on two )6w) occasions
2. LAC on two )6w) occasions )aPTT, DRVVT)
3. Exclusion of other coagulopathies
Definite aPLS is establish by at least one
criterion of each category
Yield (%)
80
70
60
50
40
30
20
10 Selected
0
Unselected
until 1993
from 1993
Thrombophilia Healthy subjects Unselected patients Selected patients

N affected % N affected % N affected %

Protein C 15,070 0.2-0.4 2,028 3.7 880 5.2

Protein S ND 2,028 2.3 752 7.4

Antithrombin 9,669 0.02 2,028 1.9 752 4.6

Factor V Leiden 16,150 4.8 1,142 18.8 162 40

2,192 0.05

PT G20210A 11,932 2.7 2,884 7.1 551 16

1,811 0.06
Thrombophilia Healthy subjects Unselected patients Selected patients

N affected % N affected % N %
affected
FVIII 534 11.8 534 23.2 60 56.7
APCR 445 8.1 337 23.4
Hcy 1,153 6.1 856 11.7
 Priority for testing
High Intermediate Low
APCR Protein C activity Fibrinogen

Factor V Leiden Free protein S antigen Thrombin time

PT G20210A Antithrombin activity FIX activity
Homocysteine Anticardiolipin Abs FXI activity
Factor VIII C677T MTHFR
Lupus anticoagulant
 Risk of recurrence of thrombosis
according to type of thrombophilia
High Intermediate Increased None

Antithrombin Protein C FVIII FVL

APL Abs Protein S Hcy FII

Prothrombin F1+2 and soluble fibrin in normal
pregnancy
SSarig )Fertility Sterility 2002(
Gris ( Thromb Haemost )1999
‫‪ ‬בן ‪ ,47‬איש עסקים‪ .‬זמן קצר לאחר הגעתו ארצה‪ ,‬לאחר טיסה‬
‫של ‪ 18‬שעות מארה"ב‪ ,‬הרגיש כאבים בחזה‪ .‬אובחן כסובל‬
‫מתסחיף ריאתי‪ .‬ברקע – יתר לחץ דם‪ ,‬מטופל קבוע בתרופות‬
‫להורדת לחץ דם ואספירין‪ .‬בבירור קרישה‪ ,‬נוגדנים‬
‫אנטיפוספוליפידים בטיטר נמוך‪ .‬יש לציין שחמש שנים לאחר‬
‫האירוע ‪ ,‬שוב לקה בתסחיף ריאתי לאחר טיסה‪.‬‬

‫‪31‬‬
A) Cabin related
 Cramped sitting position
 More in economy class
 83% Non-aisle seats
 Lower air pressure, relative hypoxia
 differ among airlines
 Low humidity and dehydration
B) Passenger related
Age over 40
Previous VTE
Thrombophilia
Hormonal Therapy
Pregnancy
Varicose veins
Cancer
Overweight
Coagulation activation in hypobaric
chamber
 Armand Trousseau (1801-1867)

“When you are undecided about the nature of the disease of the stomach, when you hesitate
among a chronic gastritis, a simple ulcer, and a carcinoma, a phlegmatia alba dolens
(thrombophlebitis) occurring in the leg or arm will put an end to your indecision and you will
be able to assert positivelythat a cancer is present.
 Endothelial damage
• Shift to procoagulant endothelium
• Invasion of cancer cells into vessel wall
 Stasis of blood
• Frequent immobilization, surgery
• Compression of blood vessels by tumor
 Changes in the blood
constituents
• Activation of clotting proteins and blood
cells
Tumor Cell Hemostatic Properties and
Tumor Biology
Tumor cell hemostatic Mechanisms of
properties malignancy
Procoagulant
Activities
Tissue Factor Coagulation- PROLIFERATION
dependent
Fibrinolytic
Activities ANGIOGENESIS
(t-PA, u-PA, u-PAR, PAI)

TC-derived Coagulation- METASTASIS

Cytokines independent
(IL-1, TNF, VEGF)

Cell Adhesion
Molecules
 Growth
Tissue
Factor/FV Invasion
IIa
Factor Xa
Metastasis
Thrombin

these processes
Angiogene
Fibrin generation plays additional roles in
Tumor cell FX
Prothrombin
FVIIa
TF
FXa Fibrinogen

Thrombin

VEGF FIBRIN

IL-8
Angiogenesis

TF

Endothelial cells
Rickles FR, and Falanga A. Thromb Res 2001
 Tumour Cell- Host Cell
Interactions at The Vascular
Site
fibrin
Localized clotting
activation Induction of monocyte
Induction of procoagulant activity
endothelial
P TC
procoagulant and P P P P PMN
adhesive P P fibrin
properties TC TC P

TC
Endothelial Cells
TC = tumor cell
P = platelet
PMN = polymorphonuclear leukocyte

Prandoni, Falanga, Piccioli, Lancet Oncology, 2005

 The bleeding diathesis of APL is most
consistent with the diagnosis of DIC.
 Primary fibrinolysis is hard to document
in APL and probably does not exist.
 Excessive fibrinolysis is probably
secondary to thrombin generation.
 ATRA can improve the coagulopathy in
patients with APL.
 Protein C
pathway
sEPCR

APC FVIIIa
sEPCR

PC
T sEPCR
FVIIIa
FVa
T
TM PC APC FVa
EPCR EPCR
S
 Acquired activated protein C resistance is common in cancer
patients and is associated with VTE

Cancer with Cancer without VTE without Normal

VTE VTE Cancer Controls

Patients 55 58 54 56

FV Leiden 1 (2%) 4 (7%) 18 (33%) 2 (4%)

APCR without 29 (54%) 9 (17%) 7 (19%) 0

FV Leiden

Haim, Am J Med 2001

:Heparanase
Heparanase activity was implicated in cellular
invasion ,angiogenesis, inflammation and
cancer metastasis

Heparanase up-regulation was documented in an

increasing number of primary solid and hematological
.human malignancies
Heparanase up-regulation correlated with reduced
postoperative survival of pancreatic, bladder, gastric,
.cervical and colorectal cancer patients
Similarly, heparanase up-regulation correlated with
increased lymph node and distant metastases,
 Hepa

Hepa

Hepa

Heparan
sulfate
 Considerations in planning treatment of
patients with thrombosis
• Efficacy of treatment
• Rate of bleeding complications
• Rate of recurrence
• Complications due to recurrence
 PT correlates
initially with FVII
thus not reflecting
actual AC
 Protein C fast drop
creates initial
hypercoagulability
 Initiation of
coumadin should
be “covered” by
heparin
INR - International Normalized Ratio

ISI
INR = R

R = PT (sec) patient / PT control

example: PT coumadin treated patient - 32 sec,

PT control - 12 sec
R = 2.6

ISI = international standartization index

 Intrinsic Extrinsic
pathway pathway

Antithrombin

ATII Xa
ATIII ATIII
I
Xa

Pentasaccharide
II IIa

Fibrinogen Fibrin
clot

Adapted with permission from Turpie et al . N Engl J Med.2001;344:619

 ORAL PARENTERAL

TF/VIIa TFPI )tifacogin)

TTP889
X IX

)APC (drotrecogin alfa

IXa
VIIIa )sTM )ART-123
Rivaroxab Va
an AT Fondaparinux
Xa
APIXABAN Idraparinux
YM150
DU-176b
II
Ximelagatran DX-9065a
Dabigatran IIa

Fibrinogen Fibrin
Adapted from Weitz & Bates, J Thromb Haemost2005