We used 55 Ala-scanned recombinant thrombin molecules to define residues important for inhibition by the serine protease inhibitor (serpin) heparin cofactor II (HCII) in the absence and presence of glycosaminoglycans. We verified the importance of numerous basic residues in anion-binding exosite-1 (exosite-1) and found 4 additional residues, Gln 24 ) remained resistant to inhibition by HCII with glycosaminoglycans. Using 11 exosite-2 thrombin mutants with 20 different mutated residues, we saw no major perturbations of HCIIglycosaminoglycan inhibition reactions. Collectively, our results support a "double bridge" mechanism for HCII inhibition of thrombin in the presence of glycosaminoglycans, which relies in part on ternary complex formation but is primarily dominated by an allosteric process involving contact of the "hirudin-like" domain of HCII with thrombin exosite-1.The blood coagulation cascade is highly regulated with the serine protease thrombin playing an essential role in both procoagulant and anticoagulant pathways. As a procoagulant, thrombin activates platelets, cleaves fibrinogen to fibrin, resulting in the formation of a fibrin clot, activates factors V, VII, and XI via a feedback mechanism, and also activates factor XIII (plasma transglutaminase) (for a review, see Ref. 1 and references cited therein). By contrast, when thrombin binds to the endothelial cell surface receptor thrombomodulin, thrombin activates the anticoagulant zymogen, protein C (for a review, see Ref. 2 and references cited therein). Macromolecular substrate recognition by thrombin is partly mediated by two clusters of positively charged basic amino acids located on opposite sides of the active site, referred to as anionbinding exosite-1 and anion-binding exosite-2 (exosite-1 and exosite-2, respectively) 1 . Exosite-1 binds fibrinogen, fibrin, heparin cofactor II (HCII) (3), and hirudin (4), whereas exosite-2 binds heparin, heparan sulfate, and dermatan sulfate (5-7).Glycosaminoglycan-accelerated inhibition by the serine protease inhibitors (serpins) antithrombin (AT; systematic name SERPINC1) (8), heparin cofactor II (HCII; systematic name SERPIND1) (9), protein C inhibitor (also known as plasminogen activator inhibitor-3; systematic name SERPINA5) (10), and protease nexin-1 (systematic name SERPINE2) (11) is one mechanism for thrombin regulation. Besides thrombin, AT inhibits several proteases in the blood coagulation pathway, including factor IXa, Xa, XIa, XIIa, plasmin, and kallikerin; however, HCII is specific for thrombin in this group of serine proteases. Although both AT and HCII inhibition of thrombin are accelerated by heparin and heparan sulfate, HCII inhibition of thrombin is also accelerated by dermatan sulfate (12, 13). The glycosaminoglycan-binding site for AT and HCII is localized to the D-helix region of these serpins (for a review, see Refs. 8 and 14 -20 and references cited therein). Recent studies show that HCII acts as a thrombin inhibitor in the arterial circulation (21) and that dermatan sulfate proteoglyca...