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Hemodynamic Disorders (3)

Alia Al-Mohtaseb

Oday Manaseer

Sunday, 26/12/2010

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 By the Name of ALLAH
Hey everybody, this is Oday Manaseer writing to you this lecture,
and wishing you the best of luck, it's gonna be absolutely amazing and
very easy.

Before we start I'd like to notify you that there are two slides haven't been discussed (#51,
52).

 Prothrombic functions :

 Platelet effects : Von Willebrand factor (in plasma) facilitates adhesion of platelets
to subendothelilal collagen (vWF is product of ECs)
 Procoagulant effects ( coagulation proteins ) :
- ECs (induced by TNF & IL-1) synthesize tissue factor (TF) which activates extrinsic
clotting pathway .
- By binding to IXa and Xa and increases its catalytic effects .
 Antifibrinolytic effects ; secretion of plasminogen activator inhibitors (PAIs)

 From our lovely book : (endothelium prothrombotic properties)

 Endothelial injury results in platelets adhesion to subendothelial collagen this occurs
through (vWf) .. vWF is synthesized largely by normal endothelium .
loss of endothelium Exposes previously deposited vWF and allows circulating vWF to , also
bind to the basement membrane in quick order platelets adhere via their Gp-Ib .
 cytokines such TNF or IL-1 as well as bacterial endotoxin all induce endothelial cell
production of tissue factor .. tissue factor activates the extrinsic clotting pathway .

 From our lovely book : ( endothelium antithrombotic

properties )

 an intact endothelium prevents platelets from

interacting with highly thrombogenic
subendothelium ECM
 if platelets are activated after focal injury they
are inhibited from adhering to the surrounding
uninjured endothelium by PGI2 and NO .
 endothelial cells elaborate ADPase whish
degrades ADP and further inhibits platelet
aggregation .
 anticoagulants effects are mediated by
membrane associated heparin like molecules
and thrombomodulin .

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** For whatever it worth this lecture covers the slides 53-75.
Now let's start with the lecture, today we are going to continue the third lecture of
Hemodynamic Disorders, we stopped last time at the platelets function which have
an important and critical role in coagulation and hemodynamic status, as you know
the normal number of platelets range 140,000 - 400,000 platelets per ml, and the
normal platelet can live (life-span) 8-10 days.

This figure shows you the structure of a platelet.

In a cross section of a platelet, you can see it has a very important two types of
granules; dense δ(delta) granules, and the α granules, these granules are important
for the platelets to be able to contribute in aggregation and to perform its function.

The platelet also has an outer membrane composed of phospholipids and protein.
And there are also microtubules which are crucial for regulation of the shape and
movement of the platelet to adhere or to move to the site of the injury. It also
contains glycogen as a source of energy, mitochondria for cellular respiration and
energy production.

As mentioned the platelets have two types of granules:

1. The Dense Granules (delta): contain ADP, ATP, Ca, Histamine, Serotonin and
Epinephrine
2. The Alpha (α) Granules: the express P-selectin and contain: Fibrinogen,
Fibronectin, PDGF, TGF-α, Platelet Factor 4 (heparin binding chemokine),
Factor V & VIII.

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There are Glycoproteins exist on the outer surface of the platelets, very important
for the platelets functions they work as receptors for clotting factors, these types of
glycoproteins and their functions are:

1. GP Ia-IIa ( GlycoProtein 1a-2a): adhesion to collagen, as we all know when we

have an endothelia injury we need adhesion of the platelets to work
properly, and since the collagen is the most abundant
vWF: von Willebrand factor,
protein in the extracellular matrix, theses glycoproteins
produced by endothelial
bind the platelets to collagen. And it's important to cells when there's injury and
know if there's any deficiency in this GP which will secreted to the plasma to
cause bleeding tendency. facilitate the adhesion of
2. GP Ic-IIa : these are laminin receptors, adhere the platelet to subendothelial
platelets to the subendothelial collagen.
3. GP IIb-IIIa: binding to fibrinogen, as we know fibrin
Any deficiency in this factor
builds up a meshwork that strengthens the process of
will affect the adhesion
coagulation. process. And this called the
4. GP Ib-IX: adhesion to subendothelial tissue via von von Willebrand disease.
Willebrand factor.

The platelets response after endothelial injury:

After injury to endothelial cells, platelets will be activated, and whenever they are
activated, they will have a change in their shape.

Normally platelets are round in shape, after activation they will get more flat like
shape and fusiform with a lot of fingerlike branches.

They become more adhesive, and will secrete their content of granules; the dense and
alpha granules, after that a numerous platelets will gather and aggregate.

Before activation After activation

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 **so what happens to the platelets after activation:
Undergo shape changes, become adhesive, secrete
contents of granules, aggregate.**

 Role of Platelets in Coagulation:

In order for the platelets to function, they have to adhere to the extracellular matrix, as we
know the flow of blood in the vessels follows a laminar fashion, where the platelets flow in
the center without any direct contact to the endothelial cells in normal statuses. but when
there's an endothelia cell injury, this laminar flow will be disturbed, the platelets starts to
flow in the periphery and contact extracellular matrix contents, specially the collagen, and
this effect is driven by the binding of GP on the platelets with the vWF as mentioned
earlier, this adhesion mostly irreversible. However this adhesion may happen without vWF
in normal situation but yet it's very weak and so neglected because of the absence of vWF.

**That was the first role for of platelets in coagulation

process after activation: Adhesion to ECM through the
vWF-GPIb effect.**

 The second role is secretion of granule contents, like: Ca++, ADP, and secretions
will result in surface expression phospholipids complexes.

Another role is secretion of granules, it's very crucial in this process; they must be
secreted into the cytoplasm to complete the activation of platelets.

This activation appears as expressing of phospholipids on the surface, these

phospholipids complexes act as binding sites for Ca++ ions in the intrinsic pathway
which will be discussed later on.

There is also ADP secreted from those granules which functions as a mediator in
platelet aggregation.

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Now, how platelets release ADP and TXA2:

Adhesion of phospholipids to collagen in ECM

will trigger the degradation of the phospholipids
membrane in order to give a final product ADP
and TXA2 through arachidonic acid pathway and
Cyclo-oxygenase pathway which was discussed
in the inflammation chapter.
cyclooxygenase pathway will result in production
of thromboxane A2 as well as Prostacyclin,
which have opposite function, you know we need
this balance between TXA2 and Prostacyclin in
normal status.
TXA2 is a very crucial granule secreted from platelets
since it function as promoter of aggregation along
with ADP as a source of energy!

 So, in pathological terms speaking, TXA2 and ADP will trigger the autocatalytic
reaction and form a primary haemostatic plug; which is a small group of platelets
aggregated together, and this will further stimulate aggregation of other platelets.

After formation of the primary haemostatic plug, the activation of coagulation

cascade will be triggered, this will result with thrombin. This thrombin will bind to
receptors on the platelets for further aggregation.

The primary haemostatic plug is a reversible complex, it's weak and only composed
of platelets aggregated to each other, so we need to make it stronger and this
accomplished by the effect of fibrin, this fibrin stabilizes and anchors the aggregated
platelets to come closer to each other and more aggregated as if they were to
contract and reduce spaces between them, ending with the formation of secondary
haemostatic plug.

Also fibrinogen plays role in formation of the secondary haemostatic plug, as we said
fibrinogen binds to GP IIb-IIIa receptors on the surface and connects large number of
platelets with each other.

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 Coagulation Cascade:
" it's a series of enzymatic conversions, turning inactivated proenzymes into
activated enzymes, and will finally produce thrombin. Thrombin will go and convert
fibrinogen into fibrin."

Fibrin is the final product of the coagulation cascade.

Each step or each reaction in this cascade composed of:

1- Enzyme
2- substrate (a proenzyme "inactivated factor")
3- cofactor (an accelerator).

These components are assembled and over a phospholipids complex

(especially in activation of factor 10 and factor 2 as we will see), and held
together by Ca++ ions. And that's why clotting tends to be localized, because
it needs a phospholipids complex to be performed on.

This figure shows some steps of the coagulation cascade, as you see there's an
activated plasma membrane works as phospholipids complex for the reaction to
occur over it.

Cofactor 10 and 2 are demonstrated. Inactive coagulation factor X (10) requires the
active cofactor 9 in order to be activated. F

actor X is the first step in the common pathway between the intrinsic and extrinsic
pathways. So factor II (which is thrombin) and actor X will be activated on the
phospholipids layer. Factor X will be activated to factor Xa, factor Xa will convert
factor II into factor IIa.

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 **Factor X and factor II are activated over the
phospholipids surface.**
These tables show the numbers of factor and what their functions are, it's only a
summary for the figures, it's all have been discussed, don't worry about it:

Number and/or name Function

Number and/or name
I (fibrinogen) Forms clot (fibrin) Function
I (fibrinogen)
II (prothrombin) Forms
Its clotform
active (fibrin)
(IIa) activates I, V, VIII, XI, XIII, protein C, platelets
II (prothrombin)
III Its active form
(Tissue factor or thromboplastin Co-factor (IIa) activates I, V, VIII, XI, XIII, protein C, platelets
of VIIa
III (Tissue
IV factor or thromboplastin Required
(Calcium) Co-factor for
of VIIa
coagulation factors to bind to phospholipid
IV(proaccelerin,
V (Calcium) labile factor) Required for
Co-factor of Xcoagulation
with whichfactors to the
it forms bindprothrombinase
to phospholipidcomplex
V (proaccelerin, labile factor)
VI Co-factor of–Xold
Unassigned with which
name it forms
of Factor Vathe prothrombinase complex
VI (stable factor)
VII Unassigned – old
Activates IX, X name of Factor Va
VII (stable
VIII factor) factor)
(antihemophilic Activates IX,
Co-factor X with which it forms the tenase complex
of IX
VIII (antihemophilic
IX (Christmas factor)factor) Co-factor of IX withtenase
Activates X: forms whichcomplex
it formswith
the tenase
factor complex
VIII
IX(Stuart-Prower
X (Christmas factor)
factor) Activates II:
Activates X: forms
forms prothrombinase
tenase complex complex
with factor VIII
with factor V
X (Stuart-Prower factor)
XI (plasma thromboplastin Activates II: forms prothrombinase complex with factor V
Activates IX
antecedent)
XI (plasma thromboplastin
Activates IX
antecedent)
XII (Hageman factor) Activates factor XI and prekallikrein
XII (Hageman
XIII factor) factor)
(fibrin-stabilizing Activates factor
Crosslinks fibrinXI and prekallikrein
XIIIWillebrand
von (fibrin-stabilizing
factor factor) Crosslinks
Binds fibrin
to VIII, mediates platelet adhesion
von Willebrand factor
prekallikrein Binds to VIII, mediates
Activates XII and platelet adhesion
prekallikrein; cleaves HMWK
prekallikrein
high molecular weight kininogen Activates XII and prekallikrein; cleaves HMWK
Supports reciprocal activation of XII, XI, and prekallikrein
(HMWK)
high molecular weight kininogen
Supports reciprocal activation of XII, XI, and prekallikrein
(HMWK)
fibronectin Mediates cell adhesion
fibronectin Mediates cell adhesion
antithrombin III Inhibits IIa, Xa, and other proteases;
antithrombin III Inhibits IIa, Xa, and other proteases;
Inhibits IIa, cofactor for heparin and dermatan sulfate ("minor
heparin cofactor II
Inhibits IIa, cofactor for heparin and dermatan sulfate ("minor
antithrombin")
heparin cofactor II
antithrombin")
protein C Inactivates Va and VIIIa
protein C Inactivates Va and VIIIa
Cofactor for activated protein C (APC, inactive when bound to C4b-
protein S Cofactorprotein)
for activated protein C (APC, inactive when bound to C4b-
protein S binding
binding protein)
Mediates thrombin adhesion to phospholipids and stimulates
protein Z Mediates thrombin adhesion to phospholipids and stimulates
protein Z degradation of factor X by ZPI
degradation of factor X by ZPI
Protein Z-related protease inhibitor
Protein Z-related protease inhibitor Degrades factors X (in presence of protein Z) and XI (independently)
(ZPI) Degrades factors X (in presence of protein Z) and XI (independently)
(ZPI)
plasminogen Converts to plasmin, lyses fibrin and other proteins
plasminogen Converts to plasmin, lyses fibrin and other proteins
alpha 2-antiplasmin Inhibits plasmin
alpha 2-antiplasmin Inhibits plasmin
tissue plasminogen activator (tPA) Activates plasminogen
tissue plasminogen activator (tPA) Activates plasminogen
urokinase Activates plasminogen
urokinase Activates plasminogen
plasminogen activator inhibitor-1
plasminogen activator inhibitor-1 Inactivates tPA & urokinase (endothelial PAI)
(PAI1) Inactivates tPA & urokinase (endothelial PAI)
(PAI1)
plasminogen activator inhibitor-2 Inactivates tPA & urokinase (placental PAI)
plasminogen activator inhibitor-2 Inactivates tPA & urokinase (placental PAI)

The doctor mentioned the first 4 factors, and then in particular she mentioned factor
9 (Christmas factor), so rakzzzo 3aleh ;).

In the second table, the doctor said that these proteins function as anti-coagulant
factor rather than promoting factors as we shall see later.

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Back to the coagulation cascade we have two pathways: the intrinsic and extrinsic
pathways, we divided them in such way according to the stimuli or the causative of
triggering of the pathway, when I say extrinsic pathway that means I need and
external stimuli to trigger it like a tissue injury that will release factor III
(thromboplastin) which will start the extrinsic pathway by activating factor VII which
in turn activates factor X, as well factor VII also activated factor IX.

*Tissue factor (Thromboplastin) is released after tissue

injury and binds to factor VII converting it to VIIa
triggering the extrinsic pathway*
There is a lot of overlapping between these two pathways, however we mainly
separate them in order to do tests to see the causative and deficiency that leads to
bleeding tendency patients. Y3ni we examine any abnormality in the intrinsic
pathway by doing the partial thromboplastic time PTT, by examining the overall
function of the factors in the intrinsic and the common pathway. And prothrombin
time PT test for the extrinsic pathway.

How these tests are done? We draw a blood sample form the patient and preserve it
in a special tubes that will prevent spontaneous clotting of blood by chelating Ca++
ions because we want the blood to stay in its liquid status, then in the lab we
measure the time needed for the factors to be activated and how many seconds
needed for the blood to be clotted, normally it ranges from 28-35 seconds, if there
was any delay in this time that means the patient either on treatment like Warfarin,
or maybe he has a bleeding tendency.

The intrinsic pathway starts by Hageman factor XII, factor XII activate XI, factor IX
along with VIII will activate factor X.

*Ca++ ions play crucial role in activation of factors:

VIII, VII and X, and conversion from prothrombin to
thrombin.*
This quick review for the cascade steps from the slides:

1. Damaged cells (extrinsic pathway) display a surface protein (tissue factor: TF)
that binds to activated Factor 7 (TF-7) to cleave: Factor 10. Some factor from
the intrinsic pathway may interfere here.
2. In the common pathway, factor 10 binds and activates Factor 5
(prothrombinase) converting prothrombin (also known as Factor II) to
thrombin.
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 3. Thrombin proteolytically cleave fibrinogen (Factor I) to fibrin which will form
the meshwork that going to add more strength to the secondary haemostatic
plug.
4. Factor 13 forms covalent bonds between the soluble fibrin molecules
converting them into an insoluble meshwork — the clot.

 There are some factors that can play a role in amplification of the clotting process;
TF-7 complex (binding of tissue factor with factor VII) will activates factor XI, factor
XI activates factor IX. Factor VIII is a protein circulates in the plasma, when it's
stabilized by the effect of vWF it will bind to factor IX. Complex of factors 9-8-vWF
will activate more and more of factors 10 and 5 which are considered part of the
common pathway.

There’s always a balance between keeping the blood free of clots and between
forming clots when needed at the site of injury, and the thrombin has a dual role. It
acts as pro-coagulant and anti-coagulant in order to keep the normal homeostasis
of the blood. so the actions of thrombin varies between coagulation and anti-
coagulation , between forming a thrombus when needed and keeping the blood
liquid in uninjured blood vessel.

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 1. Conversion of fibrinogen to fibrin.

2. Activation of factor V (which is part of the common pathway) .

3. Activation of factor VIII (which is part of the intrinsic pathway) .

4. Activation of factor XIII ( that will create the cross linkage between the fibrin
in order to form the network).

5. Activation of protein C (protein C & protein S plays an important role in anti-

coagulation).

6. Activation of platelets to adhere to the site of injury.

7. Activation of endothelial cells.

8. Activation of monocytes and leukocytes, and this is the reason why when
forming a blood clot (thrombus) you can find some erythrocytes (RBCs) and
leukocytes(WBCs) that can be within the thrombus, they are adherent and
captured within the formed thrombus. So the thrombin here works as a
chemotactic agent that attracts and activates some leukocyte and running
RBCs.

Controlling Coagulation Cascade

We said that there is a balance between coagulation and anti-coagulation so u must

have some agents to control and prevent the coagulation :

 Antithrombin III inhibits the formation of a thrombus by inactivating pro-

thrombin, Factor 9, & Factor 10 which are part of the intrinsic along with the
common pathway. Also it inactivate factor 11 & 12.

 Protein C and its cofactor Protein S (vitamin K-dependent>>>vit. K is needed

for their synthesis) together (to be fully active) inhibit thrombin formation, by
inactivating cofactors Va and VIIIa. Inherited deficiency (mutations) of Protein
C or Protein S will lead to hyper-coagulation status (thrombophilia).

 Vitamin K, as we said, is important in the synthesis of protein C &S. also, they

are important in the activation of the coagulation cascade and the
coagulation factors , because the activation of the coagulation factors
depends upon adding a carboxyl residue in the glutamic residue part , it’s all
vit. K dependent. So vit. K is a cofactor needed for the synthesis (in the liver)
of factors II, VII, IX, and X, proteins C and S. Deficiency of Vitamin K

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 predisposes to bleeding. Conversely, blocking the action of vitamin K helps to
prevent inappropriate clotting >>> so it plays a role in coagulation cascade
and anti- coagulation cascade (I don’t know about this but this is what the
doctor said).

 The doctor mentioned a ”plasmin activator” but didn’t explain anything

about it

 From our lovely book :

-- Fibrinolysis is largely accomplished by the enzymatic activity of plasmin which

breaks down fibrin and interferes with its polymerization .

--The resulting fibrin spilt products (FSBs) or fibrin degradation products can also
act as anticoagulants

 TEPI : IS A PROTEIN SECRETED BY ENDOTHELIUM ( and other cell types ) but inactivates
factor Xa and tissue factor – VIIa complexes .

.
Anti-coagulant drugs:
1. Heparin is an anti- coagulant drug which binds to and enhances anti-
thrombin III activity.

2. Warfarin is an effective vitamin K antagonist, and as we said vit. K plays an

important role in coagulation.

So in order to Controlling Coagulation Cascade and prevent the clot formation in

normal blood vessel, we have to limit the size of the final clot that is made of
activated platelet that are adherent to each other and fibrin molecules that are
cross-linked to form the secondary haemostatic . So the plug (clot) has to be limited
to the site of the injury only where the endothelial cells have been injured.

And we can do that by the cleavage of the plasminogen.Plasmin has an important

role in the confinement of the clots. Plasminogen usually is running through the
plasma protein and it’s cleaved into the active form which is plasmin, and this is
done by factors of the coagulation, meaning that whenever we have a coagulation
cascade, the anti-coagulation will be activated as well to keep balance

It’ll be triggered by factor XII (part of the intrinsic pathway) which will cleave the
plasminogen and give the activated plasmin which is ( t-PA)t stands for tissue
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because it’s released from the tissues. However we have other sources of
plasminogen activator such as bacteria. Some bacteria produce endotoxin that has
the effect of plasminogen activator which is to release activated plasmin which
breaks down fibrin into fibrin split products.

Fibrin split products are very important to tell if the patient has a hyper-coagulant
status because it’s the end product of fibrinolysis , so if their levels are elevated in
the serum that means that the patient has DIC ( Disseminated intravascular
coagulation ). Fibrin split products are measured by what we call D dimers in the
clinical lab.

Normally, free plasmin is inactivated by binding to α2-antiplasmin so that excess

plasmin does not lyse clots elsewhere in the body (unneeded clots, harmful clots) so
you’ll have a balance between anti-plasmin and plasminogen activator.

Endothelial cells (ECs) have an important role in the pro-thrombotic and anti-
thrombotic activity , because it releases ,along with the tissue factors ,plasminogen
activator inhibitors so they activate coagulation by inhibiting the plasminogen
activator.

Thrombosis:
It's a pathological status we don't want it, in which there is formation of intra-
vascular solid masses (thrombus) from the elements of the circulating blood.

These vessels where the thrombus exists may remain uninjured or have a minor
injury.

There are 3 main factor that influence thrombus formation, we call them Virchow's
Triad:

1. Endothelia injury
2. Stasis or turbulence in blood flow, which is disturbances in the laminar
fashion flow of blood.
3. Blood hypercoagulatory status

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And here how this triad works, Endothelial injury is the most crucial component.

When I have an endothelial cell injury the blood flow will become abnormal, and also
haypercoagulability will lead to abnormal blood flow.

** We are gonna discuss each one of these components:

1. Endothelial injury:
It's the main cause of thrombosis mainly in the heart and arterial circulation,
because of the high pressure of blood entering the heart and arteries it's important
for the endothelial cells to stay intact and healthy.

Injuries to EC can be caused by many factors:

- The Myocardial Injury, as a result of myocardial infarction or valvular disease

like valvulitis.
- Ulcerated plaque in atherosclerosis.
- Toxins released when smoking cigarettes.
- Traumatic and inflammatory conditions.

Another EC injury type may exist as Dysfunctional Endothelium; alteration in the

dynamic balance of prothrombotic and antithrombotic effects. This type of injury
caused by:

- Hemodynamic stresses; the common cause of such stresses are hypertension,

turbulent flow over scarred valves, or bacterial endotoxins.
- Homocystinuria
- Hypercholesterolemia, that causes atherosclerosis as we all know.
- Products absorbed from cigarette smoke
- Radiation and extensive burns
-

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Endothelial cell injury results in:

1. Exposure of subendothelial collagen.

2. Adherence of platelet.

3. Release of tissue factor, which trigger the extrinsic pathway.

4. Depletion of plasminogen activators and prostacyclin. Prostacyclin of course is a

vasodilator and crucial for hemodynamic status.

2. Alteration in blood flow:

Any turbulence in blood flow will lead to EC injury or dysfunction; and to a stasis
(blood static (rokood) in blood vessels) which is the major cause of venous
thrombosis.

Stasis and turbulences in blood flow lead to:

- Disruption of the laminar flow, where the platelets will be running in the
periphery and in contact with endothelium instead of being in the center.
- Prevent dilution (not being concentrated in one place) of activated clotting
factors that are running through the blood by fresh-flowing blood.
- Decrease inflow of coagulation factor inhibitors and permit the build-up of
thrombi.
- Help activate endothelial cells leading to thrombosis and leukocyte adhesion

Clinical condition that will cause Turbulences and Stasis:

1. Ulcerated atherosclerosis plaque, whenever I have a plaque in a blood vessel

and if it was ulcerated it will cause turbulence and stasis of blood.
2. Abnormal aortic and arterial dilations (aneurysms).
3. Acute myocardial infarction (aneurysm), because the ventricle cells are dead
and aren't able to contract properly, it will cause stasis and dilatation in blood
vessels.
4. Atrial fibrillation (arrhythmia) and atrial dilation that caused by mitral valve
stenosis (rheumatic heart disease)
5. Hyperviscosity syndromes (polycythemia: increase in red blood cells count)
6. Sickle cell anemia: abnormal RBC will static and coagulate around each other
and form thrombus.

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 The third component of Virchow's triad "Hypercoagulability" will be discussed in the
next lecture.

They take pictures of mount climbers at the top of the mountain;

they're smiling, ecstatic, triumphant. However they don't take pictures
along the way, coz who wants to remember the rest of it??!... We push
ourselves because we have to, not because we like it! The restless
climb, the pain and the anguish of taking it to the next level, nobody
takes pictures of that, nobody wants to remember. We just wanna
remember the view from the top, the breath-taking moment at the
edge of the world, that's what keeps us climbing…and it worth the
pain, that crazy part it worth anything =)...

I'm coming home

I'm coming home

Tell the World I'm coming home

Let the rain wash away, all the pain of yesterday

I know my Kingdome (family) awaits, and they've forgiven my mistakes

I'm coming home, I'm coming home

...all my friends, my world is a BETTER place with you in it <3…

Oday Manaseer

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