Objective: Plasma thrombin generation (TG) provides important information on coagulation status; however, current TG output parameters do not predict major bleeding of patients on anticoagulants.... Show moreObjective: Plasma thrombin generation (TG) provides important information on coagulation status; however, current TG output parameters do not predict major bleeding of patients on anticoagulants. We recently reported that factor V (FV) activation by factor X (FX)a contributes importantly to the initiation phase of TG. Here we investigated how this pathway varies in the normal population and whether FXa-mediated activation of FV is associated with major bleeding in patients on anticoagulant therapy. Approach: We employed TIX-5, a specific inhibitor of FV activation by FXa, to estimate the contribution of FXa-mediated FV activation to tissue factor (TF)-initiated TG. Results: We show that the contribution of this pathway to plasma TG varies considerably in the normal population, as measured by the time needed to form the first traces of thrombin (TG lag time; mean prolongation by TIX-5 40%, range 0%-116%). Comparing patients on vitamin K antagonists (VKA) of the BLEED study (263 patients with and 538 patients without major bleeding), showed a marked prolongation in the median TG lag time in the presence of TIX-5 in cases (12.83 versus 11.00 minutes, P = 0.0030), while the TG lag time without TIX-5 only showed a minor although significant difference (5.83 vs. 5.67 minutes, P = 0.0198). The TIX-5 sensitivity (lag time + TIX-5/lag time + vehicle) in the upper quartile was associated with a 1.62-fold (95% confidence interval 1.04-2.52) increased risk of major bleeding compared to the lowest quartile. Conclusion: A greater dependence on FXa-mediated activation of FV of TG is associated with increased risk of major bleeding during VKA therapy. Show less
The venom of the Australian brown snake Pseudonaja textilis contains a prothrombinase-like initiator of blood coagulation, which has evolved into a potent weapon through several gainof-function... Show moreThe venom of the Australian brown snake Pseudonaja textilis contains a prothrombinase-like initiator of blood coagulation, which has evolved into a potent weapon through several gainof-function adaptations. Here we examined the functional implications of a disulfide bond exclusively found in the factor (F)Va-like cofactor component, ptFV. We found that this remarkable structural feature is not required for the procoagulant properties of ptFV. The nearly identical liver-derived plasma ptFV that lacks this disulfide link displayed a similar procoagulant profile. Whether the unique disulfide bond imposes conformational constraints essential to other aspects of the venom FV life cycle remains to be determined. Show less
