Fibrinolysis TPA cleaves __ to __ Plasmin cleaves __into __ Three inhibitors: 1. _ 2. _ 3. _

Fibrinolysis TPA cleaves plasminogen to plasmin Plasmin cleaves fibrin into fibrin split products Three inhibitors 1. Alpha two antiplasmin inhibits plasmin 2. PAI inhibits plasminogen 3. TAFI (thrombin activatable fibrinolysis inhibitor) inhibits binding of plasminogen and TPA to fibrin

Anticoagulation Thrombomodulin Activated protein C + protein S (its carrier) AT

Anticoagulation Thrombomodulin binds to thrombin to activate protein C Activated protein C + protein S (its carrier) inhibit FV and FVIII AT binds to heparin and inhibits conversion of II to IIa also inhibits Xa action Liver-produced

Platelets cell-surface antigens The GP (glycoprotein) Ib/V/IX complex: receptor for __ CD__ The GP IIb/IIIa complex: receptor for __ platelet antigen __ a/w GP IIIa __ alleles, __ Platelet antigens __ a/w GP IIb CD41 = __ CD61 = __ GP Ia/IIa complex: __receptor __ GP Ic/IIa complex: __receptor Red cell antigens: __ Class __ MHC antigens Passively adsorbed __

Platelets cell-surface antigens The GP (glycoprotein) Ib/V/IX complex: receptor for vWF CD42 The GP IIb/IIIa complex: receptor for fibrinogen platelet antigen PLA a/w GP IIIa 2 alleles, PLA1 and PLA2 Platelet antigens baka and bakb a/w GP IIb CD41 = GP IIb/IIIa CD61 = GP IIIa GP Ia/IIa complex: collagen receptor Bra/Brb GP Ic/IIa complex: fibronectin receptor Red cell antigens: ABO, I, i, P, Le (no Rh antigens) Class I MHC antigens Passively adsorbed IgG and coagulation factors

Control of Coagulation Thrombin concentration controlled by: __degradation __ Thrombin activation controlled by: __ inactivates thrombin and __ can be stimulated by __ __ __ __ thrombin combines with __ on endothelial cell surfaces forming __ complex that converts __ to __ __ inactivates__, with __as its cofactor Plasmin primary agent of __degradation formed from __which is structurally incorporated into the fibrin clot Tissue plasminogen activator (tPA) converts __to __ released from __ following injury exposure to __activates tPA Plasmin is controlled by:

Control of Coagulation Thrombin concentration controlled by: fibrin degradation tissue factor pathway inhibitor (TFPI) inhibition of the tissue factor-FVIIa-FXa complex Thrombin activation controlled by: Antithrombin inactivates thrombin and FIXa, FXa, FXIa and FXIIa can be stimulated by heparin (basis for therapy) α2-macroglobulin heparin cofactor II α1-antitrypsin thrombin combines with thrombomodulin on endothelial cell surfaces forming thrombin-TM complex that converts protein C to activated protein C (APC) APC inactivates FVa and FVIIIa, with protein S as its cofactor Plasmin primary agent of fibrin degradation formed from plasminogen which is structurally incorporated into the fibrin clot Tissue plasminogen activator (tPA) converts plasminogen to plasmin released from vascular endothelial cells following injury mechanisms for fibrin degradation and formation set into motion simultaneously exposure to fibrin activates tPA Plasmin is controlled by: rapid degradation by α2-antiplasmin inhibition by plasminogen activator inhibitors (PAI-1 and PAI-2)

Platelet aggregometry Pre-analytical no aspirin or NSAIDs for __ days tubes kept at __ temp (__causes platelet activation) test performed within __ hours sample of__ (prepared by?) sample stirred continuously within a cuvette while being exposed to various agonists light transmission through the sample __as aggregation takes place optical density __ Is there spontaneous aggregation? adult __% platelet aggregation (__in newborns) in response to platelet agonists: __ biphasic curve (primary and secondary wave of aggregation) __ monophasic curve (primary aggregation only) __ ___ response with concentration \>1.2 mg/mL little to no response \<0.8 mg/mL __ response follows a short lag Monitor release of platelet dense granules (secondary wave) during aggregation assay __ using __ assay

Platelet aggregometry Pre-analytical no aspirin or NSAIDs for \>7 days tubes kept at room temp (cold causes platelet activation) test performed within 2 hours sample of platelet-rich plasma (slow-centrifugation of whole blood) sample stirred continuously within a cuvette while being exposed to various agonists light transmission through the sample increases as aggregation takes place optical density decreases no spontaneous aggregation adult \>60% platelet aggregation (less in newborns) in response to platelet agonists: (AACRE) ADP, Arachidonate, Collagen, Ristocetin, Epinephrine biphasic curve (primary and secondary wave of aggregation) low-dose ADP and epinephrine monophasic curve (primary aggregation only) high-dose ADP, collagen, ristocetin ristocetin response with concentration \>1.2 mg/mL little to no response \<0.8 mg/mL collagen response follows a short lag Monitor release of platelet dense granules (secondary wave) during aggregation assay secreted ATP using firefly luminescence assay

Abnormal aggregometry most common cause of abnormal aggregometry is __ decreased aggregation with arachidonate no secondary phase with epinephrine and ADP poor response to epinephrine response to everything but risotocetin poor response to all agents except ristocetin

Abnormal aggregometry most common cause of abnormal aggregometry is a medication decreased aggregation with arachidonate aspirin/aspirin-like agents no secondary phase with epinephrine and ADP storage pool defects and aspirin poor response to epinephrine myeloproliferative diseases response to everything but risotocetin von Willebrand disease and Bernard-Soullier syndrome poor response to all agents except ristocetin Glanzmann thombasthenia

Giant Platelets Lying about how big your plts are: FIB GAMMMES Fechner syndrome ITP Bernard Soulier Gray platelet syndrome Alport syndrome May Hegglin Montreal plt syndrome Mediterranean macrothromocytosis Epstein syndrome Sebastian syndrome

Storage Pool Deficiency Decreased plt __due to deficiencies in __ __morphology, __ on EM Plt agg studies: __ __ collagen & AA __ristocetin __ATP:ADP ratio 5 Examples of Storage Pool Deficiency

Storage Pool Deficiency Decreased plt aggregation due to deficiencies in dense/alpha granules Normal morphology, no granules on EM Plt agg studies: No 2nd wave ADP, EPI Decreased collagen & AA Normal ristocetin ↑ ATP:ADP ratio 5 Examples of Storage Pool Deficiency (Quebec is Gray, Cold & Wet, never Hot) Quebec plt disorder Gray platelet syndrome Chediak Higashi Wiscott Aldrich syndrome Hermansky-Pudlak Syndrome

Heme/Coag Flashcards by Nicola Dundas

Platelet granules

Alpha
Delta (dense)

Platelet granules

Alpha granule
- thromboglobulin
- P-selectin
- PDGF
- PF4
- platelet fibrinogen
- thrombospondin
- VWF
Delta (dense) granule [Delta’s CASA]
- Ca++
- ATP
- Serotonin
- ADP dense granule -> vasoconstriction

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Fibrinolysis

TPA cleaves __ to __
Plasmin cleaves __into __

Three inhibitors:

Fibrinolysis

TPA cleaves plasminogen to plasmin
Plasmin cleaves fibrin into fibrin split products

Three inhibitors

Alpha two antiplasmin inhibits plasmin
PAI inhibits plasminogen
TAFI (thrombin activatable fibrinolysis inhibitor) inhibits binding of plasminogen and TPA to fibrin

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Anticoagulation

Thrombomodulin
Activated protein C + protein S (its carrier)
AT

Anticoagulation

Thrombomodulin
- binds to thrombin to activate protein C
Activated protein C + protein S (its carrier)
- inhibit FV and FVIII
AT
- binds to heparin and inhibits conversion of II to IIa
- also inhibits Xa action
- Liver-produced

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Platelets cell-surface antigens

The GP (glycoprotein) Ib/V/IX complex:
- receptor for __
- CD__
The GP IIb/IIIa complex:
- receptor for __
- platelet antigen __ a/w GP IIIa
  - __ alleles, __
- Platelet antigens __ a/w GP IIb
- CD41 = __
- CD61 = __
GP Ia/IIa complex:
- __receptor __
GP Ic/IIa complex:
- __receptor
Red cell antigens:
- __
Class __ MHC antigens
Passively adsorbed __

Platelets cell-surface antigens

The GP (glycoprotein) Ib/V/IX complex:
- receptor for vWF
- CD42
The GP IIb/IIIa complex:
- receptor for fibrinogen
- platelet antigen PLA a/w GP IIIa
  - 2 alleles, PLA1 and PLA2
- Platelet antigens baka and bakb a/w GP IIb
- CD41 = GP IIb/IIIa
- CD61 = GP IIIa
GP Ia/IIa complex:
- collagen receptor Bra/Brb
GP Ic/IIa complex:
- fibronectin receptor
Red cell antigens:
- ABO, I, i, P, Le (no Rh antigens)
Class I MHC antigens
Passively adsorbed IgG and coagulation factors

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Extrensic Pathway

Intrinsic Pathway

The Common Pathway

Extrensic Pathway

FVII
tissue injury leads to the release of tissue factor (III)
FVIIa cleaves factor X to factor Xa
Xa is capable of activating VII to VIIa
VIIa capable of activating IX to IXa, so in vivo activation of VII can propel the intrinsic pathway
- major mechanism by which the administration of FVIIa exerts its therapeutic effect

Intrinsic Pathway

FXII, FXI, FIX, FVIII, prekallikrein, and HMWK (plus calcium and phospholipids)
endpoint is conversion of factor X to factor Xa
initiated by the proximity of prekallikrein, HMWK, FXII and FXI to one another and to a negatively charged surface (contact phase)
- early evolutionion (ocean/sand)
results in conversion of prekallikrein to kallikrein, which activates FXII to FXIIa
XIIa activates more prekallikrein to kallikrein, establishing a cycle
activation of FX carried out by the tenase complex (Calcium, FVIIIa, FIXa) on plt surface
Platelets
- when activated, express an abundance of phosphatidylserine (PS) and phosphatidylinositol (PI) on surface
- facilitate attachment of the tenase complex
Xa is capable of activating VII to VIIa, thus providing a link with the intrinsic pathway

The Common Pathway

FX, FII, and fibrinogen
Xa converts FII (prothrombin) to FIIa (thrombin)
thrombin converts fibrinogen (I) to fibrin (Ia)
prothrombinase complex forms on the surfaces of platelets
- anchored by PS and PI
- consists of Va and Xa
Fibrinogen is composed of pairs of three polypeptides:
- A-α, B-β, γ
- A and B are referred to as fibrinopeptides (FpA and FpB)

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Control of Coagulation

Thrombin concentration controlled by:
- __degradation
- __
Thrombin activation controlled by:
- __
  - inactivates thrombin and __
  - can be stimulated by __
- __
- __
- __
- thrombin combines with __ on endothelial cell surfaces forming __ complex that converts __ to __
  - __ inactivates__, with __as its cofactor
Plasmin
- primary agent of __degradation
- formed from __which is structurally incorporated into the fibrin clot
Tissue plasminogen activator (tPA)
- converts __to __
- released from __ following injury
- exposure to __activates tPA
Plasmin is controlled by:

Control of Coagulation

Thrombin concentration controlled by:
- fibrin degradation
- tissue factor pathway inhibitor (TFPI)
  - inhibition of the tissue factor-FVIIa-FXa complex
Thrombin activation controlled by:
- Antithrombin
  - inactivates thrombin and FIXa, FXa, FXIa and FXIIa
  - can be stimulated by heparin (basis for therapy)
- α2-macroglobulin
- heparin cofactor II
- α1-antitrypsin
- thrombin combines with thrombomodulin on endothelial cell surfaces forming thrombin-TM complex that converts protein C to activated protein C (APC)
  - APC inactivates FVa and FVIIIa, with protein S as its cofactor
Plasmin
- primary agent of fibrin degradation
- formed from plasminogen which is structurally incorporated into the fibrin clot
Tissue plasminogen activator (tPA)
- converts plasminogen to plasmin
- released from vascular endothelial cells following injury
  - mechanisms for fibrin degradation and formation set into motion simultaneously
- exposure to fibrin activates tPA
Plasmin is controlled by:
- rapid degradation by α2-antiplasmin
- inhibition by plasminogen activator inhibitors (PAI-1 and PAI-2)

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PLATELET AGGREGATION STUDIES

Optical density (%)
- w/ aggregation __
- __and __are weak agonists and biphasic

PLATELET AGGREGATION STUDIES

Optical density (%)
- w/ aggregation, less light scattering, lower optical density
- ADP and epinephrine are weak agonists and biphasic

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Platelet aggregometry

Pre-analytical
- no aspirin or NSAIDs for __ days
- tubes kept at __ temp (__causes platelet activation)
- test performed within __ hours
sample of__ (prepared by?)
sample stirred continuously within a cuvette while being exposed to various agonists
light transmission through the sample __as aggregation takes place
- optical density __
Is there spontaneous aggregation?
adult __% platelet aggregation (__in newborns) in response to platelet agonists:
- __
biphasic curve (primary and secondary wave of aggregation)
- __
monophasic curve (primary aggregation only)
- __
___
- response with concentration >1.2 mg/mL
- little to no response <0.8 mg/mL
__
- response follows a short lag
Monitor release of platelet dense granules (secondary wave) during aggregation
- assay __ using __ assay

Platelet aggregometry

Pre-analytical
- no aspirin or NSAIDs for >7 days
- tubes kept at room temp (cold causes platelet activation)
- test performed within 2 hours
sample of platelet-rich plasma (slow-centrifugation of whole blood)
sample stirred continuously within a cuvette while being exposed to various agonists
light transmission through the sample increases as aggregation takes place
- optical density decreases
no spontaneous aggregation
adult >60% platelet aggregation (less in newborns) in response to platelet agonists:
- (AACRE)
- ADP, Arachidonate, Collagen, Ristocetin, Epinephrine
biphasic curve (primary and secondary wave of aggregation)
- low-dose ADP and epinephrine
monophasic curve (primary aggregation only)
- high-dose ADP, collagen, ristocetin
ristocetin
- response with concentration >1.2 mg/mL
- little to no response <0.8 mg/mL
collagen
- response follows a short lag
Monitor release of platelet dense granules (secondary wave) during aggregation
- assay secreted ATP using firefly luminescence assay

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Abnormal aggregometry

most common cause of abnormal aggregometry is __
decreased aggregation with arachidonate
no secondary phase with epinephrine and ADP
poor response to epinephrine
response to everything but risotocetin
poor response to all agents except ristocetin

Abnormal aggregometry

most common cause of abnormal aggregometry is a medication
decreased aggregation with arachidonate
- aspirin/aspirin-like agents
no secondary phase with epinephrine and ADP
- storage pool defects and aspirin
poor response to epinephrine
- myeloproliferative diseases
response to everything but risotocetin
- von Willebrand disease and Bernard-Soullier syndrome
poor response to all agents except ristocetin
- Glanzmann thombasthenia

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Response to everything but risotocetin

von Willebrand disease and Bernard-Soullier syndrome

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Poor response to all agents except ristocetin

Glanzmann thombasthenia

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Congenital Platelet Disorders

Bernard-Soulier Disorder
Glanzmann thrombasthenia
May Hegglin

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___

What type of problem?
Defect __ (CD__)
Can’t bind __
Thrombocytopenia?
__PT, PTT, ___bleeding time
Impaired __ aggregation
Platelet flow cytometry shows ↓ __

Bernard-Soulier

Adhesion problem
Defect GPIb/V/IX (CD42)
Can’t bind vWF
Large giant platelet w pseudonucleolus
Thrombocytopenia
Normal PT, PTT, increased bleeding time
Impaired ristocetin aggregation
If you add normal ptls + ristocetin, aggregation will be nl b/c the abnormality is on the patients plt.
Platelet flow cytometry shows ↓ CD42a, b and d (GPIba, V and IX)

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___

__problem
Plts can’t bind __
Abnormal __
Thrombocytopenia?
Plt aggregation studies?
Dx: Flow cytometry shows ↓ __
Differential diagnosis
- _& _
  - both defect in__ interactions
- __normal PT/PTT
- __↑PT/PTT

Glanzmann thrombasthenia

Aggregation problem
Plts can’t bind fibrinogen
Abnormal GP IIb-IIIa
Normal plt count
Poor response to all agents except ristocetin
Dx: Flow cytometry shows ↓ CD41 (GPIIb) and CD61 (GPIIIa)
Differential diagnosis
- Glanzmanns & Afibrinogenima
  - both defect in fibrin:fibrin interactions
- Glanzmann’s normal PT/PTT
- Afibrinogenemia ↑PT/PTT

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May Hegglin Anomaly

Mutation
Inheritance
Thrombocytopenia?
PMN function?

May Hegglin Anomaly

Mutation in myosin heavy chain 9 gene
Autosomal dominant
WBC inclusion (Dohle-like) + Giant plt
Thrombocytopenia, but little bleeding
PMN function is normal

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Giant Platelets

Lying about how big your plts are: FIB GAMMMES

Fechner syndrome
ITP
Bernard Soulier
Gray platelet syndrome
Alport syndrome
May Hegglin
Montreal plt syndrome
Mediterranean macrothromocytosis
Epstein syndrome
Sebastian syndrome

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Storage Pool Deficiency

Decreased plt __due to deficiencies in __
__morphology, __ on EM
Plt agg studies:
- __
- __ collagen & AA
- __ristocetin
- __ATP:ADP ratio
5 Examples of Storage Pool Deficiency

Storage Pool Deficiency

Decreased plt aggregation due to deficiencies in dense/alpha granules
Normal morphology, no granules on EM
Plt agg studies:
- No 2nd wave ADP, EPI
- Decreased collagen & AA
- Normal ristocetin
- ↑ ATP:ADP ratio
5 Examples of Storage Pool Deficiency (Quebec is Gray, Cold & Wet, never Hot)
- Quebec plt disorder
- Gray platelet syndrome
- Chediak Higashi
- Wiscott Aldrich syndrome
- Hermansky-Pudlak Syndrome

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Storage Pool Deficiency

Storage Pool Deficiencies

5 Examples of Storage Pool Deficiency (Quebec is Gray, Cold & Wet, never Hot)

Quebec plt disorder
- No α granules
Gray platelet syndrome
- No α granules
- Large gray plts, no granules
- From cardio pulmonary bypass
- Plt agg blunted with all agents except ADP/EPI
Chediak Higashi
- No δ granules EM
Wiscott Aldrich syndrome
- x-linked
- No δ granules EM
- Small granulated plts, like FeDa
- Thrombocytopenia, infection, eczema
- Increased malignancy
Hermansky-Pudlak Syndrome
- No δ granules EM
- pigment reticuloendothelial cell
- Swiss cheese platelets
- ↑AK, nevi, tumors, pulmonary fibrosis
- Puerto Rican/Swiss, ↑vWF
- Thrombocytopenia w absent radii

Aspirin/NSAIDS

Decrease platelet function by:
- acetylation of platelet __ -> decreased __formation
Platelet aggregation studies

Aspirin/NSAIDS

Decrease platelet function by:
- acetylation of platelet cyclooxygenase -> decreased thromboxane formation
Platelet aggregation studies
- No 2nd wave ADP and epi
- Absent response to collagen and arachidonic acid

Other platelet type bleeding disorders

Hereditary Telangectasia
Ehlers Danlos, Type 4
Henoch-schonlein
Arteriovenous malformation
Scurvy
Marfans, osteogenesis imperfecta, fabry syndrome
Amyloidosis

Other plt type bleeding disorders

Hereditary Telangiectasia
- Osler-Weber-Rendu
- Oral Telangiectasia FeDA
Ehlers Danlos, Type 4
- Connect tissue disorder plts cant stick, bruising and prupura, loose skin
Henoch-schonlein
- Vasculitis, prupura, thrombocytopenia
Arteriovenous malformation
- ↓plts
Scurvy
- decreased Vit C, bad teeth, perifollicular petechiae
Marfans, osteogenesis imperfecta, fabry syndrome
Amyloidosis
- decreased factor X
- platelets don’t stick, endothelium coated, lambda light chains

Von Willebrand factor and disease

vWF binds to:
- __
- __
Large multimers cleaved by __
- deficiency of __ a/w __
Made in __(α granules) and endothelial cells (__)
vWD most common__
↓vWF-blood type__
Quant/qual deficiencies?
Secondary vWF deficiency?

Von Willebrand factor and disease

vWF binds to:
- F8 and stabilizes it
- subendothelial collagen and GPIba
Large multimers cleaved by ADAMTS-13
- deficiency of ADAMTS-13 a/w TTP
Made in megakaryocytes (α granules) and endothelial cells (Weibel-Palade bodies)
vWD most common genetic Plt type bleeding disorder
↓vWF-blood type O, old blood sit
Quant or qual deficiencies
Secondary vWF deficiency
- Wilms tumor
- congenital heart disease
- hypothyroid

VWD diagnostic tests

Platelet count
- __
FVIIICo
- __
vWF Ag
- __
vWF:Rcof
- __
RIPA (Ristocetin induced platelet aggregation)
- _
__
__
__

VWD diagnostic tests

Platelet count
- Plts ↓sometimes, screening test
FVIIICo
- measure F8 activity
vWF Ag
- measures vWF quantity
- blood add F8 -> measure vWF
vWF:Rcof
- measures vWF activity
- Pt plasma + nl plts + ristocetin, then measure time to aggregation
- very specific & most sensitive test
- Quantitate pt vWF activity (%) using ristocetin, standard curve with quantitative endpoint
RIPA (Ristocetin induced platelet aggregation)
- pts plasma + pt plts + low dose ristocetin = time to aggregation
- all or none, does pt aggregate with ristocetin
Platelet agg studies
VWF multimers
Mixing study

vWD Type I

multimers?
frequency?
tests?
treated w DDAVP?

vWD type 2a and 2b

Type 2a
- multimers?
- tests?
- treated w DDAVP?
Type 2b
- multimers?
- tests?
- treated w DDAVP?
- mutation?

Type 3

inheritance?
multimers?
tests?
treated w DDAVP?

vWF 2M and 2N

Type 2M
- multimers?
- tests?
- treated w DDAVP?
Type 2N (Normandy)
- genetics?
- multimers?
- tests?
- treated w DDAVP?
Frequency

vWD Type I

Low quantity, normal multimers, functionally normal
Most common type
Sometimes all tests are normal
Only type treated w DDAVP

vWD type 2a and 2b

Type 2a
- Decreased large and medium sized multimers
- Disproportionately low vWF:RCo (quality) relative to vWFAg (quantity)
Type 2b
- Mutation in exon 28 of VWF that causes increased affinity of VWF for GP1bα
- Decreased high molecular weight (HMW) multimers
- Leads to increase clearance of vWF
- Increased RIPA
- No DDAVP
- Test: mutations in exon 28 of VWF gene

Type 3

Autosomal recessive, most AD
Severe marked deficiency
Absence of vWF, F8 also low
But may have nl coag parameters
vW multimer test, all multimers low
No DDAVP

vWF 2M and 2N

Type 2M
- Defect in GP 1b binding, but no loss of HMW multimers
- vWF made but doesn’t work
- Decreased vWFRco
- +/- normal RIPA, vWF Ag, F8
- Suspect when vwf:RCo < vWF ag
Type 2N (Normandy)
- Defective binding of vWF to F8
- Hemophilia-like (but AR), women w low F8, think of this dz
- Tests: decreased FVIII, decreased vWFAg:C levels
- Normal RIPA, multimers, ristocetin
- Normal sequence analysis of F8 gene to rule out hemophilia
Frequency
- 2A>2N>2M>2B

vWD Type I * multimers? * frequency? * tests? * treated w DDAVP?

vWD Type I * Low quantity, normal multimers, functionally normal * Most common type * Sometimes all tests are normal * Only type treated w DDAVP

vWD type 2a and 2b * Type 2a * multimers? * tests? * treated w DDAVP? * Type 2b * multimers? * tests? * treated w DDAVP? * mutation?

vWD type 2a and 2b * Type 2a * Decreased large and medium sized multimers * Disproportionately low vWF:RCo (quality) relative to vWFAg (quantity) * Type 2b * Mutation in exon 28 of VWF that causes increased affinity of VWF for GP1bα * Decreased high molecular weight (HMW) multimers * Leads to increase clearance of vWF * Increased RIPA * No DDAVP * Test: mutations in exon 28 of VWF gene

Type 3 * inheritance? * multimers? * tests? * treated w DDAVP?

vWD Type 3 * Autosomal recessive, most AD * Severe marked deficiency * Absence of vWF, F8 also low * But may have nl coag parameters * vW multimer test, all multimers low * No DDAVP

vWF 2M and 2N * Type 2M * multimers? * tests? * treated w DDAVP? * Type 2N (Normandy) * genetics? * multimers? * tests? * treated w DDAVP? * Frequency

vWF 2M and 2N * Type 2M * Defect in GP 1b binding, but no loss of HMW multimers * vWF made but doesn’t work * Decreased vWFRco * +/- normal RIPA, vWF Ag, F8 * Suspect when vwf:RCo * Type 2N (Normandy) * Defective binding of vWF to F8 * Hemophilia-like (but AR), women w low F8, think of this dz * Tests: decreased FVIII, decreased vWFAg:C levels * Normal RIPA, multimers, ristocetin * Normal sequence analysis of F8 gene to rule out hemophilia * Frequency * 2A\>2N\>2M\>2B

Pseudo VWF—platelet type * Mutations in __ resulting in ↑ binding of \_\_to __ multimers * The abnormality is on the patients \_\_, not with \_\_ * VW multimer test shows __ vWF multimers * \_\_RIPA studies * Platelet agg studies show \_\_ * Aggregation with \_\_ * Mutations in *\_\_*gene, whereas __ has mutations in exon 28 of *VWF* gene

Pseudo VWF—platelet type * Mutations in GP1ba resulting in ↑ binding of GPIba to HMW VWF multimers * The abnormality is on the patients platelets (GP1b), not with vWF * Plts bind large VWF multimers * VW multimer test shows decreased large vWF multimers * Abn RIPA studies * Platelet agg studies show low dose ristocetin aggregation * Aggregation with cryoprecipitate * Mutations in *GP1bα* gene, whereas VWF 2B has mutations in exon 28 of *VWF* gene

Factor deficiencies * Hemophilia A – decreased factor \_\_ * Hemophilia B – decreased factor \_\_ * Bleeding into \_\_ * __ PT/PTT * __ bleeding time * Symptoms rare if factor level \> \_\_%; severe disease if levels \< \_\_% * Chr \_\_, 50% intron \_\_inversion

Factor deficiencies * Hemophilia A – decreased factor VIII * Hemophilia B – decreased factor IX * Bleeding into joints * Increased PT/PTT * Often normal bleeding time * Symptoms rare if factor level \> 15-20%; severe disease if levels \< 1% * Chr (Xq28), 50% intron 22 inversion

Thrombophilia Inherited disorders of thrombosis * \_\_ * 6% Caucasians * \_\_ * 2% Caucasians * \_\_ * Less common * __ deficiency * __ deficiency * \_\_ Acquired risk of thrombosis (4)

Thrombophilia Inherited disorders of thrombosis * Resistance of activated protein C * 6% Caucasians * Prothrombin *G20210A* mutation * 2% Caucasians * Protein C deficiency * Less common * Protein S deficiency * Antithrombin III deficiency * Hyperhomocysteinemia Acquired risk of thrombosis * Heparin Induced Thrombocytopenia * Oral contraceptives * Lupus anticoagulant * Estrogen replacement therapy

Activated Protein C Resistance * Fequency? * Usually __ point mutation, which prevents inactivation by protein C, so __ production is unchecked, leading to thrombosis * __ gene Mutation: * Arg for gln at position 506 (\_\_) * Arg for threonine at position 306 (\_\_) * Mutation in __ and \_\_ Dx * Functional assay:\_\_\_ * Screening test * If pt **doesn't have** APCR and you add ProtC to their specimen, ↑ PTT \_\_ * If patient **has** APCR and you add ProtC to their specimen, ↑ PTT \_\_ * PCR for \_\_

Activated Protein C Resistance * Most common cause of thrombophilia * Usually Factor V point mutation, which prevents inactivation by protein C, so prothrombin production is unchecked, leading to thrombosis * Factor V gene Mutation: * Arg for gln at position 506 (Factor V Leiden) * Arg for threonine at position 306 (Factor V Cambridge) * Mutation in factor II and methylene tetrahydrafolate reductase (MTHFR) Dx * Functional assay: PTT:resistance ratio * Screening test * If pt **doesn't have** APCR and you add ProtC to their specimen, ↑ PTT \>2:1 * If patient **has** APCR and you add ProtC to their specimen, ↑ PTT \<2:1 * PCR for Factor V Leiden mutations

Protein C Deficiency * \_\_heterozygous, homozygous \_\_ * Genetic cases have \_\_risk of thrombosis * acquired \_\_ * \_\_thromboembolism * Coumadin -\> \_\_ * Laboratory diagnosis: * Patient must be off \_\_

Protein C Deficiency * Usually heterozygous, homozygous die in infancy * Genetic cases have increased risk of thrombosis * acquired usually don't * Venous thromboembolism * Coumadin -\> skin necrosis * Laboratory diagnosis: * Patient must be off Coumadin

Protein S Deficiency * Prot S is a \_\_to Prot C * 40% is \_\_ * 60% Protein S binds to \_\_\_ * * \_\_is an acute phase reactant * increased \_\_-\> decreased Protein S * Thus __ during stress (pregnancy) * Labs: * __ (worst test) * __ (best test) * Inheritance? * Oral contraceptives, estrogen therapy and pregnancy * decrease protein S, but not \_\_\_

Protein S Deficiency * Prot S is a cofactor to Prot C * 40% is free, functional protein S * 60% Protein S binds to C4b binding protein * C4b is an acute phase reactant * increased C4b -\> decreased Protein S * Thus ↓ Prot S during stress (pregnancy) * Labs: * total protein S (worst test) * protein S activity (best test) * Autosomal dominant * Oral contraceptives, estrogen therapy and pregnancy * decrease protein S, but not protein C or antithrombin

Antithrombin III deficiency * Antithrombin binds to \_\_to inhibit factors \_\_ * In ATIII deficiency, patient presents w ↓response to \_\_ * Acquired- \_\_ * If a patient has thrombosis that you treat with \_\_and the PT does not rise sufficiently, the patient may have ATIII deficiency

Antithrombin III deficiency * Antithrombin binds to heparin to inhibit factors II and X. * In ATIII deficiency, patient presents w ↓response to heparin * Acquired- liver, nephrotic dz, DIC * If a patient has thrombosis that you treat with heparin and the PT does not rise sufficiently, the patient may have ATIII deficiency

Prothrombin G20210A Mutation * \_\_mutation leads to \_\_prothrombin levels * \_\_is the location of the mutation in the gene * Guanidine to adenine substitution in the 3’ untranslated portion of prothrombin gene on Chr \_

Prothrombin G20210A Mutation * Point mutation leads to high prothrombin levels * 20210 is the location of the mutation in the gene * Guanidine to adenine substitution in the 3’ untranslated portion of prothrombin gene on Chr 11

Anti-phospholipid syndrome * Heterogeneous group of autoantibodies associated with prolongation of\_\_ clotting assays and \_\_thrombosis * antibodies against phospholipids * \_\_ * Most common * \_\_ * \_\_ * \_\_platelets, \_\_thrombosis * Originally described in patients with \_\_, but most cases develop in patients without \_\_

Anti-phospholipid syndrome * Heterogeneous group of autoantibodies associated with prolongation of phospholipid dependent clotting assays and ↑thrombosis * antibodies against phospholipids * Beta2-glycoprotein * Most common * Anticardiolipin antibodies * Lupus anticoagulant * ↓platelets, increased thrombosis * Originally described in patients with SLE, but most cases develop in patients without SLE

Antiphospholipid antibody tests * PTT \_\_ * Dilute Russell viper venom test * Russell Viper venom + __ activates Factor \_\_ * Plasma containing lupus Abs \_\_PTT * Mixing study * Shows evidence \_\_activity * __ fails to correct w mixing study, but partial correction w adding \_\_ * Anticardiolipin antibody * \_\_NO ↑PTT * must be + on __ occasions \_\_weeks apart to exclude \_\_ * β2 Glycoprotein I antibodies * must be + on __ occasions \_\_weeks apart to exclude \_\_ * Platelet neutralization procedure * PTT fails to correct w mixing study, but corrects when you add \_\_ * Rule out other coagulopathies * Specifically \_\_ * \_\_\_ * Falsely positive

Antiphospholipid antibody tests * PTT prolonged * Dilute Russell viper venom test * Russell Viper venom + Factor V, phospholipid and calcium activates Factor X. * Plasma containing lupus Abs prolongs PTT * Mixing study * Shows evidence inhibitor activity * ↑PTT fails to correct w mixing study, but partial correction w adding phospholipid * Anticardiolipin antibody * ELISA NO ↑PTT * must be + on 2 occasions 12 weeks apart to exclude transient Abs from another illness * β2 Glycoprotein I antibodies * must be + on 2 occasions 12 weeks apart to exclude transient Abs from another illness * Platelet neutralization procedure * PTT fails to correct w mixing study, but corrects when you add hexagonal phase phosphatidyl ethanolamine * Rule out other coagulopathies * Specifically other inhibitors * Nontreponemal VDRL/RPR * Falsely positive

Heparin induced thrombocytopenia and thrombosis (HITT) * \_\_Ab to __ in __ granules * \_\_% unfractionated heparin * Less in \_\_ * __ plts usually after\_\_ * Thrombosis * Treatment * __ heparin/ \_\_warfarin * Give plts? * \_\_, monitored by PTT * Diagnosis * Numerous assays; patient blood add \_\_look for \_\_ * Serotonin release assay * Measure plt \_\_ * Pt given low dose \_\_, radioactive labeled \_\_released * Pt given high dose \_\_, __ if patient has HITT * PF4 ELISA * __ test, measures \_\_ * rapid turnaround, but often false \_\_

Heparin induced thrombocytopenia and thrombosis (HITT) * IgG Ab to heparin PF4 complex in α granules * ~8% unfractionated heparin * Less in LMW or porcine heparin * ↓ plts usually after 5-8 days * Thrombosis * Treatment * Stop heparin/ no warfarin * Platelets release granules so don’t give plts * Thrombin inhibitors, monitored by PTT * Diagnosis * Numerous assays; patient blood add heparin look for coagulation * Serotonin release assay * Measure plt granule release * Pt given low dose heparin, radioactive labeled serotonin released * Pt given high dose, no serotonin released if patient has HITT * PF4 ELISA * best test, measures Abs * rapid turnaround, but often false +

Homocysteinemia * Inheritance, \_\_dislocate, \_\_, peripheral \_\_ * sometimes \_\_↓ * Dx * \_\_levels * __ mutation * Mutation in \_\_

Homocysteinemia * AR, lens dislocate, MR, peripheral neuropathy * sometimes folate ↓ * Dx * serum levels * Methyl tetrahydrofolate reductase mutation * Mutation in CBS cysathionine βsynthase

Pregnancy * \_\_coagulability * Increase in factors\_\_ * Decrease \_\_ * \_\_remain constant * Resistance to \_\_ * \_\_stasis * Risk of \_\_

Pregnancy * Hypercoagulability * Increase in factors⁭VII, VIII, IX, X, PAI & fibrinogen * Decrease protein S * Protein C and ATIII remain constant * Resistance to activated Prot C * Venous stasis * Risk of PE and DVT

Liver * Liver synthesizes all clotting factors except \_\_ * End stage liver disease results in \_\_hemostasis * \_\_clotting factors * Factor __ are sensitive indicators * Factor \_\_falls first * __ may be increased due to increased vWF * \_\_is an acute phase reactant so it may be normal or decreased * Vit __ deficiency * \_\_

Liver * Liver synthesizes all clotting factors except VW factor * End stage liver disease results in failed hemostasis * Reduces clotting factors * Factor V and VII are sensitive indicators * Factor VII falls first * Factor VIII may be increased due to increased vWF * Fibrinogen is an acute phase reactant so it may be normal or decreased * Vit K deficiency * DIC

Heparin * Unfractionated heparin is monitored by \_\_ * Adequate anticoagulation is when __ is __ x mean normal heparin * Heparin prolongs PTT, DRVVT and shows inhibitory effect with mixing studies * lab testing can look like \_\_ * LMWH is monitored by \_\_

Heparin * Unfractionated heparin is monitored by PTT * Adequate anticoagulation is when PTT is 2x mean normal heparin * Heparin prolongs PTT, DRVVT and shows inhibitory effect with mixing studies * lab testing can look like antiphospholipid syndrome * LMWH is monitored by anti-factor Xa

aPTT * Phospholipid (contact activator of FXII- (silica, kaolin, etc) + excess Ca + citrated plasma * time to clot formation = PTT * screen for factor deficiency * Prolongation of the PTT is caused by deficiencies of * XII, XI, IX, VIII (intrinsic pathway constituents) * X, V, II, fibrinogen (common pathway) * an inhibitor * Prolongation of PT and PTT - deficiencies of factors * X, V, II, fibrinogen (the common pathway) * inhibitor * to cause prolonged PTT * factor \< 30% * higher if multiple factor deficiencies * PTT more sensitive to deficiencies in intrinsic than common pathway factors * elevated FVIII level * capable of shortening the PTT