Patients with antiphospholipid antibodies (APLAs) are at increased risk for arterial and venous thrombosis. Many APLAs associated with these events react with  2 glycoprotein I ( 2 GPI), and endothelial cell reactive antibodies that activate endothelial cells in a  2 GPI-dependent manner occur commonly in these patients. We previously reported that  2 GPI binds with high affinity to annexin A2 on the endothelial surface, though the relevance of this interaction to APLA/anti- 2 GPI antibodyinduced endothelial activation has not been determined. In this report, we confirm that anti- 2 GPI antibodies activate endothelial cells in the presence of  2 GPI, and demonstrate that anti-annexin A2 antibodies directly cause endothelial cell activation of a similar magnitude and with a similar time course. Moreover, bivalent anti-annexin A2 F(ab) 2 fragments also caused endothelial cell activation, whereas monomeric Fab fragments not only did not cause activation, but blocked activation induced by anti-annexin A2 antibodies and F(ab) 2 fragments, as well as that caused by anti- 2 GPI antibodies in the presence of  2 GPI. These observations suggest a novel pathway for endothelial activation induced by APLA/anti- 2 GPI antibodies that is initiated by crosslinking or clustering of annexin A2 on the endothelial surface. (Blood. 2005;105: 1964-1969