Definition. Hemostasis is the mechanism that leads to cessation of bleeding from a blood vessel. It is a process that involves multiple interlinked steps. This cascade culminates into the formation of a “plug” that closes up the damaged site of the blood vessel controlling the bleeding. It begins with trauma to the lining of the blood vessel.
Stages. The mechanism of hemostasis can divide into four stages. 1) Constriction of the blood vessel. 2) Formation of a temporary “platelet plug." 3) Activation of the coagulation cascade. 4) Formation of “fibrin plug” or the final clot.
Purpose. Hemostasis facilitates a series of enzymatic activations that lead to the formation of a clot with platelets and fibrin polymer. This clot seals the injured area, controls and prevents further bleeding while the tissue regeneration process takes place. Once the injury starts to heal, the plug slowly remodels, and it dissolves with the restoration of normal tissue at the site of the damage.
Hyper-coagulation. The hemostatic cascade is meant to control hemorrhage and be a protective mechanism. At times, this process is triggered inadvertently while the blood is within the lumen of the blood vessel and without any bleeding. This situation leads to a pathologic phenomenon of thrombosis, which can have catastrophic complications by obstructing blood flow leading to ischemia and even infarction of the tissues supplied by the occluded blood vessels. In this way, a physiologic process becomes a pathologic process leading to morbidity and/or mortality. Some of the examples include Antiphospholipid antibody syndrome, Factor 5 Leiden mutation, Protein C deficiency, protein S deficiency, Prothrombin gene mutation, etc.
Hypo-coagulation. When there is any defect in the functionality of any component of this hemostatic cascade, it can lead to ineffective hemostasis and inability to control hemorrhage; this can lead to severe blood loss, hemorrhage and also complications that can hence ensue due to the inhibited blood supply to vital organs. Some of the examples include Von Willebrand disease, hemophilia, disseminated intravascular coagulation, deficiency of the clotting factors, platelet disorders, collagen vascular disorders, etc.
Iatrogenic Coagulopathy. Medicine is currently in the era of widespread use of antiplatelet agents like aspirin, clopidogrel, ticagrelor and anticoagulants like warfarin, heparin, low molecular weight heparin, rivaroxaban, apixaban, dabigatran, fondaparinux amongst others for various commonly encountered clinical conditions like cardiac stenting/ percutaneous coronary intervention, atrial fibrillation, deep venous thrombosis, pulmonary embolism, and many more. The way these medications affect the functionality of the various components of clotting cascade can help patients with their clinical conditions. However, it can lead to bleeding/thrombosis in cases of inappropriate dosage, non-compliance, medication interactions, and result in significant morbidity and mortality.
There are various cellular components in the process of coagulation. Most notably are those processes associated with the endothelium, platelets, and hepatocytes.
Endothelium. Clotting factors III and VIII originate from the endothelial cells while the clotting factor IV comes from the plasma. Factor III, IV, and VIII all undergo K dependent gamma-carboxylation of their glutamic acid residues, which allows for binding with calcium and other ions while in the coagulation pathway.
Platelets. These are non-nucleated disc-like cells created from megakaryocytes that arise from the bone marrow. They are about 2 to 3 microns in size. Some of their unique structural elements include plasma membrane, open canalicular system, spectrin and actin cytoskeleton, microtubules, mitochondria, lysosomes, granules, and peroxisomes. These cells release proteins involved in clotting and platelet aggregation.
Hepatocytes. The liver produces the majority of the proteins that function as clotting factors and as anticoagulants.
Embryology. The development of the coagulation system begins in the fetus. The various clotting factors and the coagulation proteins initially get expressed in the endothelial cells during early gestation. They usually are undetectable in the plasma until after the first trimester. There is a transient gap in the development and maturation of the hemostatic proteins from the early second trimester until term due to some unclear mechanisms. Due to the similar structure and functionality of the hemostatic coagulative proteins in the fetus and the similarity in the platelet expression, there is a rarity in the occurrence of any thrombotic/hemorrhagic complications in the healthy fetus unless there is any form of uteroplacental insufficiency due to any maternal or fetal factors.
The physiology of hemostasis involves the:
All of these systems help with the production of the clotting factors, vitamins, and cells for appropriate functionality of hemostasis.
Hemodynamic Stability. Under normal circumstances, there exists a fine balance between the procoagulant and anticoagulant pathway. This mechanism ensures control of hemorrhage as needed and cessation of pro-coagulant pathway activation beyond the injury site/or without any bleeding. When this equilibrium becomes compromised under any condition, this may lead to thrombotic/bleeding complications. The hemostatic system also helps in wound healing.
Cardiovascular System. PGA1 and PGA2 cause peripheral arteriolar dilation. Prostacyclin produces vasodilation, and thromboxane A2 causes vasoconstriction. Prostacyclin inhibits platelet aggregation and produces vasodilation whereas thromboxane A2 and endoperoxides promote platelet aggregation and cause vasoconstriction. The balance between the prostacyclin and thromboxane A2 determines the degree of platelet plug formation. Thus, prostaglandins greatly influence temporary hemostasis.
Vaso Constriction. Within about 30 minutes of damage/trauma to the blood vessels, vascular spasm ensues, which leads to vasoconstriction. At the site of the disrupted endothelial lining, the extracellular matrix (ECM)/ collagen becomes exposed to the blood components.
Platelet Adhesion. This ECM releases cytokines and inflammatory markers that lead to adhesion of the platelets and their aggregation at that site which leads to the formation of a platelet plug and sealing of the defect. The platelet adhesion is a complex process mediated by interactions between various receptors and proteins including tyrosine kinase receptors, glycoprotein receptors, other G-protein receptors as well as the von Willebrand Factor (vWF). The von Willebrand Factor functions via binding to the Gp 1b-9 within the platelets.
Platelet Activation. The platelets that have adhered undergo very specific changes. They release their cytoplasmic granules that include ADP, thromboxane A2, serotonin, and multiple other activation factors. They also undergo a transformation of their shape into a pseudopodal shape which in-turn leads to release reactions of various chemokines. P2Y1 receptors help in the conformational changes in platelets.
Platelet Aggregation. With the mechanisms mentioned above, various platelets are activated, adhered to each other and the damaged endothelial surface leading to the formation of a primary platelet plug.
Extrinsic Pathway. The tissue factor binds to factor VII and activates it. The activated factor VII (factor VIIa) further activates factor X and factor IX via proteolysis. Activated factor IX (factor IXa) binds with its cofactor – activated factor VIII (factor VIIIa), which leads to the activation of factor X (factor Xa). Factor Xa binds to activated factor V (factor Va) and calcium and generates a prothrombinase complex that cleaves the prothrombin into thrombin.
Intrinsic Pathway. With thrombin production, there occurs conversion of factor XI to activated factor XI (factor XIa). Factor XIa with activated factor VII and tissue factor converts factor IX to activated factor IX (factor IXa). The activated factor IX combines with activated factor VIII (factor VIIIa) and activates factor X. Activated factor X (factor Xa) binds with activated factor V (factor Va) and converts prothrombin to thrombin. Thrombin acts as a cofactor and catalysis and enhances the bioactivity of many of the aforementioned proteolytic pathways.
Fibrin Clot Formation. The final steps in the coagulation cascade involve the conversion of fibrinogen to fibrin monomers which polymerizes and forms fibrin polymer mesh and result in a cross-linked fibrin clot. This reaction is catalyzed by activated factor XIII (factor XIIIa) that stimulates the lysine and the glutamic acid side chains causing cross-linking of the fibrin molecules and formation of a stabilized clot.
Clot Resolution (Tertiary Hemostasis). Activated platelets contract their internal actin and myosin fibrils in their cytoskeleton, which leads to shrinkage of the clot volume. Plasminogen then activates to plasmin, which promotes lysis of the fibrin clot; this restores the flow of blood in the damaged/obstructed blood vessels.
Indications. The assessment of platelet function as well as its dysfunction has become vital in the current era in multiple clinical scenarios; several examples are:
Coagulation Cascade Specific. There has been the development of various tests that evaluate specific events in the coagulation cascade.
General Principle. The Virchow’s triad of hypercoagulability, vascular stasis, and vascular trauma, described in 1856, remains a true predictor of thrombosis.
Etiologies. The physiology of coagulation undergoes alteration due to various factors, including:
Clinical Presentations. With the altering of hemostatic physiology, various clinical outcomes including:
Coagulopathies. Few of the disorders of coagulation include:
Risk Factors. Some acquired factors influencing the coagulation include:
As discussed above, there are various hypercoagulable and hypercoagulable conditions resulting from defects in the coagulation pathways. The full extent is beyond the scope of this topic. Here are several examples:
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