Vox Sanguinis (2004) 87 (Suppl.

1), S43S46

ORIGINAL PAPER

ES04.01

2004 Blackwell Publishing

Physiology of haemostasis

Blackwell Publishing, Ltd.

B. T. Colvin
Haemophilia Centre, Barts and The London NHS Trust, Department of Haematology, Royal London Hospital, London, UK

Introduction
The potential of the blood to coagulate must be one of the
most ancient facts of scientific knowledge. By the end of
the 19th century, it was understood that an inert precursor,
prothrombin, could be activated in the presence of thrombokinase and calcium to produce thrombin and that thrombin
was able to convert fibrinogen to fibrin. It was also known
that platelets played a part in this process. Before the Second
World War the prothrombin time was described, heparin was
discovered, and it was realized that people with haemophilia
were deficient in a factor present in the globulin fraction of
plasma.
After the War, Ratnoff and Davie in the USA and Macfarlane in the UK described the waterfall and cascade theories
of blood coagulation, which helped to explain the increasingly complex function of the rapidly expanding numbers of
discovered coagulation factors. Their presence was often
revealed by the existence of patients with specific inherited
deficiencies, and it became apparent that a series of delicate,
balanced and dynamic reactions was taking place to secure
the formation of a stable blood clot capable of preceding the
process of wound healing while maintaining the circulation.
In more recent years there has been a growing interest in
the causes of arterial and venous thrombosis as the problems
created by an ageing population have arisen and it has become
necessary to revise the model proposed 40 years ago. Nevertheless, the essential elements of haemostasis remain the
vessel wall, the platelets, and the blood coagulation and fibrinolytic mechanisms.
I propose to consider the way the system works in the light
of the circumstances in which it can go wrong, concentrating
on an explanation of how various defects, demonstrable in
the laboratory, have such strikingly different clinical consequences. One way of doing this is to divide the subject into a
sequence of four stages, namely (1) initiation; (2) amplification;

Correspondence: B. T. Colvin, Director, Haemophilia Centre, Barts and The

London NHS Trust, Department of Haematology, Royal London
Hospital, London R1 1BB, UK
E-mail: brian.colvin@bartsandthelondon.nhs.uk

(3) formation; and (4) consolidation and dissolution. I will

then examine each in the light of disorders of haemostasis
and thrombosis.

Initiation
The haemostatic mechanism is permanently active as blood
flows through intact vessel walls, lined by living endothelial
cells. This activity is largely undertaken by these cells as they
express heparan sulphate, proctacyclin, nitric oxide, thrombomodulin and plasminogen activator. Platelet endothelial
interaction does occur at rest, as demonstrated by the development of purpura in severe thrombocytopenia, implying that
platelets have an endothelial repair function (Fig. 1).
Disruption of a vessel wall causes alteration in blood
flow, reflex vasoconstruction, endothelial stripping, collagen
exposure and platelet activation. The platelets aggregate, making
available and releasing their granule contents, including adenosine diphosphate, thromboxane A2 and serotonin. A chain
reaction ensues with the formation of the primary platelet
plug, fixed by the presence of collagen, endothelial, platelet
and plasma von Willebrand factor (VWF), and platelet
glycoprotein binding sites. This may be all that is necessary
for small wounds and people with haemophilia rarely bleed
badly from minor cuts, such as those caused by shaving. By
contrast, some vessel wall abnormalities, platelet glycoprotein
deficiencies (Glanzmanns disease (IIb/IIIa) or Bernard Soulier
syndrome (Ib)), and the various forms of von Willebrand
disease can result in an immediate failure of haemostasis.
Various abnormalities of the storage pool and platelet metabolism also create relatively ill-defined platelet disorders,
and the study of platelets has resulted in a number of antiplatelet agents of varying potency and clinical value.
In thrombotic thrombocytopenic purpura, VWF is thought
to play a critical role in causing inappropriate spontaneous
platelet endothelial interaction. In this condition, there is failure
of control of VWF molecular size due to a metalloprotease
deficiency, and the net result is small vessel occlusion, especially
in the brain and kidneys, sometimes with fatal consequences.
The coagulation mechanism (Fig. 2) is partly initiated by
collagen exposure and partly by tissue factor (TF), and to this
extent the traditional concept of the intrinsic and extrinsic
systems may seem to be valid, but it is now believed that TF
43

44 B. T. Colvin

Fig. 1 An overview of haemostasis. By kind permission of Professor John

Pasi.

Fig. 2 The coagulation mechanism. By kind permission of Professor John

Pasi.

and its ability to complex with activated factor VII (VIIa) is

the fundamental step in vivo. The TF:VIIa complex then has
two functions, the direct activation of factor X, opposed by
tissue factor pathway inhibitor, and the stimulation of the
amplification system, in which platelet phospholipid (PF3)
will also play a critical role.
There is little information on defects of the initiation of
coagulation but factor VII deficiency is increasingly seen in
the homozygous or doubly heterozygous state in the UK and
is associated with abnormal bleeding.

Amplification
The amplification step produces the explosive production of
the thrombin burst, and the process is rather like running a
bath. In order to fill the bath quickly the taps are turned full

on (but the temperature of the water must be regulated).

When the bath reaches the desired level, the taps must be
turned off quickly to avoid a damaging flood.
Thrombin generation takes place at and stimulates the
production of the PF3 surface, but the reaction is driven by
the direct activation of factor IX by the TF:VIIa complex. In
the presence of factor VIII and calcium ions, factor X is activated. Factor Xa then activates prothrombin in the presence
of factor V and calcium ions and so thrombin is generated.
The thrombin formed stimulates a positive feedback loop
to accelerate platelet activity and produce the thrombin
burst. This reaction is also partly dependent on factor XI,
but not factor XII and the other contact factors. Thus can be
explained the overwhelming importance of factor VIII and
factor IX in managing the pace of thrombin generation and
also the nature and similarity of haemophilia A and B, while
factor XI deficiency is less serious. The point is that the blood
does coagulate in haemophilia but not fast enough to form a
useful clot in the right timeframe. In the presence of factor
VIII antibodies the thrombin burst is also prevented. This can
happen in autoimmune acquired haemophilia or in patients
with true haemophilia who have developed antibodies to
factor VIII. It is thought that the administration of pharmacological quantities of recombinant factor VIIa is able to
achieve haemostasis by driving the generation of thrombin
in the absence of the physiological factor VIII-dependent
step. A similar but less clear mechanism of action probably
explains the successful use of activated prothrombin complex concentrates in such cases.
Thrombin also has the property of breaking down factors
V and VIII, thus bringing the thrombin burst to a halt, and
this is achieved by the activation of protein C in the presence
of protein S. Activated protein C cleaves factor V at position
506, the mutation Arg506Gln being responsible for the
factor V Leiden variant. Antithrombin acts as a direct thrombin
inhibitor, limiting the potential for the uncontrolled generation of thrombin and the consequent propagation of thrombosis (Fig. 3).
The effectiveness of bringing the reaction to a halt is therefore dependent on many factors, and research in the latter
part of the 20th century implicated inherited deficiencies of
antithrombin, protein C and protein S to explain premature
or inappropriate thrombosis. The factor V Leiden variant
provides a fascinating insight into this balance, while there
is more and more interest in the idea that high concentrations
of clotting factors, including prothrombin, and factors VII,
VIII, IX and XI may be associated with thrombosis and are
often genetically determined. For instance, the prothrombin
variant G20210A causes an increase in prothrombin concentration, leading to a thrombophilic state.
The action of warfarin may also be explained at this point.
Administration of warfarin causes reduction in the effective
concentrations of factors II, VII, IX and X, and proteins C and

2004 Blackwell Publishing Ltd. Vox Sanguinis (2004) 87 (Suppl. 1), S43S46

Physiology of haemostasis 45

The most important of the therapeutic antithrombins

are the heparins and their analogues, which are also factor
X antagonists, but in recent years new direct antithrombins
such as hirudin and ximelagatran have been developed and
are coming into clinical use. Such antithrombins make the
blood non-coagulable and one of the advantages of the
traditional forms of unfractionated heparin is that it can be
immediately neutralized by protamine.

Consolidation and dissolution

Fig. 3 The action of antithrombin, protein C and protein S.

S. This is achieved by prevention of vitamin K-dependent

gamma carboxylation of the precursor proteins and the
failure of calcium binding. The net result is an anticoagulant
effect but it should be noted that the shortest half-life of
these factors is that of protein C, so that on commencing
warfarin therapy a brief period of hypercoagulability occurs.
Homozygous protein C deficiency is associated with fatal
neonatal thrombosis (purpura fulminans) unless immediate
replacement therapy is offered.

Formation
As thrombin is generated fibrinogen is activated and fibrin
is formed. This is a well-understood reaction involving the
specific cleaving of the inert fibrinogen molecule to create
active fibrin monomer, which then polymerizes to fibrin
polymer. Hypofibrinogenaemia, not surprisingly, results in
an abnormal bleeding tendency, but even quite small amounts
of fibrinogen seem to be sufficient to support reasonably
effective haemostasis. Patients with very low levels of fibrinogen may experience spontaneous bleeding, including
intracranial haemorrhage, and prophylactic treatment with
concentrates is sometimes necessary. Some snake venoms cause
abnormal fibrinogen activation by cleaving at specific sites to
create ineffective non-polymerizing fibrin and some of these
venoms have been used therapeutically as anticoagulants.
Paradoxically some inherited abnormalities of the fibrinogen molecule have been associated with a prothrombotic
state, while high concentrations of fibrinogen, which may
also be genetically determined, have also been linked with
thrombosis. Meanwhile, various abnormalities of the naturally
occurring serine protease inhibitor antithrombin, already briefly
mentioned, have been described, and antithrombin deficiency
was one of the earliest known causes of thrombophilia.

The blood clot consists of red cells, white cells and platelets,
bound by fibrin polymer and attached to the subendothelial
surface. In order to consolidate this structure, there is a further step of fibrin cross-linking, which is under the control
of factor XIII. This is a transamidase with a very long halflife and is responsible for cross-linking fibrin to form a secure
framework.
Inherited factor XIII deficiency is rare and is only seen
clinically in the homozygous state, as so little activity is
required to ensure haemostasis. Interestingly, the clinical
pattern is rather characteristic, with bleeding from the umbilical cord stump at birth, intracranial haemorrhage and failure
of wound healing. Rarely acquired inhibitors of factor XIII
are encountered and are also associated with an abnormal
bleeding tendency.
At the same time that blood clot is being formed and consolidated, the process of dissolution has already commenced
in the separate but related system of fibrinolysis. Once again,
an inert precursor, plasminogen, is converted to a powerful
enzyme, plasmin, in the presence of an activating stimulus,
while inhibitors are on hand to limit the process. Fibrinolytic
activator is derived from endothelium and other body tissues
as tissue plasminogen activator, while the urinary tract
produces urokinase. None of this is very evident at rest and
plasminogen activator inhibitor limits the process, but once
stimulated effectively, plasminogen is transformed into
plasmin as lysine binding sites are exposed during activation.
Plasmin then undertakes the progressive degradation of fibrin into ever-smaller fragments, culminating in the production of D-dimer and E fragments. The activity of plasmin
is normally regulated by the presence of 2 antiplasmin
while thrombin activatable fibrinolysis inhibitor is capable of
inhibiting fibrinolysis via both suppression of plasmin activation and of plasmin itself. This naturally occurring defence
against the release of plasmin into the circulation is limited
and is capable of being overwhelmed.
A deficiency of 2 antiplasmin causes a bleeding tendency
but other heritable abnormalities of the system are less
well described. When the defences against fibrinolysis are
exceeded, as may occur in some malignancies or associated
with disseminated intravascular coagulation (DIC), then
wholesale destruction of fibrin, fibrinogen, other coagulation

2004 Blackwell Publishing Ltd. Vox Sanguinis (2004) 87 (Suppl. 1), S43S46

46 B. T. Colvin

factors and other proteins takes place so that gross evidence

of fibrinolysis may become detectable on simple laboratory
testing. It should be noted that the presence of D-dimer is an
indication that cross-linked fibrin has been broken down,
implying that in vivo activation of haemostasis has occurred.
This test is used to assist in the screening of patients suspected to be suffering from venous thromboembolism.

Conclusion
The haemostatic mechanism is complex and delicately balanced.
Major defects at critical points probably result in non-viability,
while homozygous protein C deficiency creates a disorder
that is fatal in the neonatal period. Haemophilia can result in
a severe bleeding diathesis but the many and varied genetic
errors in factor production produce a range of conditions
that, at one end of the spectrum, are so mild as to be difficult
to detect, and at the other, can be fatal. It is thought that up
to 1% of the population may be described as having von
Willebrand disease and the factor V Leiden variant is even
more common.
It is generally the case that any therapeutic intervention to
promote haemostasis results in a thrombotic tendency, while
any attempt to limit the process results in the risk of abnormal
bleeding. Of particular interest is the phenomenon of DIC,
in which in vivo haemostatic activation results in thrombosis,

often in small vessels, associated with defibrination and

bleeding from a circulation in which the blood may have
been rendered non-coagulable. One of the features of DIC is
that the built-in defence mechanisms to inappropriate initiation, amplification, formation, consolidation or dissolution
are overwhelmed and it may be very difficult to restore the
equilibrium.
It is the responsibility of haematologists to find the right
haemostatic balance for each of our patients, but before we
consider the assessment and correction of haemostatic
failure, we should first take a moment to admire a system
that, in a dangerous environment, serves us well for most of
our lives.

Suggested reading
Luchtman-Jones L, Broze GJ: The current status of coagulation. Ann
Med 1995; 27:47 52
Mann KG: Biochemistry and physiology of blood coagulation.
Thrombosis Haemostasis 1999; 82:165 174
Pasi KJ: Haemostasis: components and processes in haemostasis
and thrombosis protocols; in Perry DJ, Pasi KJ (eds): Methods in
Molecular Medicine. New Jersey, Humana Press, 1999:3 21
George JN: Platelets. Lancet 2000; 355:1531 1539
Dahlback B: Blood coagulation. Lancet 2000; 355:1627 1632
Roberts HR: Oscar Ratnoff: his contributions to the golden era of
coagulation research. Br J Haematol 2003; 122:180 192

2004 Blackwell Publishing Ltd. Vox Sanguinis (2004) 87 (Suppl. 1), S43S46