Factor (f) IXa is a critical enzyme for the formation of stable blood clots, and its deficiency results in hemophilia. The enzyme functions at the confluence of the intrinsic and extrinsic pathways by binding to fVIIIa and rapidly generating fXa. In spite of its importance, little is known about how fIXa recognizes its cofactor, its substrate, or its only known inhibitor, antithrombin (AT). However, it is clear that fIXa requires extensive exosite interactions to present substrates for efficient cleavage. Here we describe the 1.7-Å crystal structure of fIXa in its recognition (Michaelis) complex with heparin-activated AT. It represents the highest resolution structure of both proteins and allows us to address several outstanding issues. The structure reveals why the heparin-induced conformational change in AT is required to permit simultaneous active-site and exosite interactions with fIXa and the nature of these interactions. The reactive center loop of AT has evolved to specifically inhibit fIXa, with a P2 Gly so as not to clash with Tyr99 on fIXa, a P4 Ile to fit snugly into the S4 pocket, and a C-terminal extension to exploit a unique wall-like feature of the active-site cleft. Arg150 is at the center of the exosite interface, interacting with AT residues on β-sheet C. A surprising crystal contact is observed between the heparin pentasaccharide and fIXa, revealing a plausible mode of binding that would allow longer heparin chains to bridge the complex.hemophilia | hemostasis | pentasaccharide | protease | thrombosis B lood coagulation (hemostasis) is traditionally described as two separate cascades of proteolytic activation events, the so-called intrinsic and extrinsic pathways (1, 2) (for a recent review, see ref.3). The extrinsic pathway is initiated by tissue damage that exposes tissue factor (TF) and subendothelial matrix proteins to the blood. Platelets adhere to collagen, and circulating factor (f) VIIa binds to and is activated by TF. The fVIIa-TF complex (extrinsic Xase) activates fX, and fXa in the presence of fVa produces thrombin. Just enough thrombin is generated at this stage for the formation of an initial clot through platelet activation; however, unless much more thrombin is produced in short order, the clot will not persist and bleeding will result. The second stage of hemostasis utilizes components of the intrinsic pathway, factors VIIIa and IXa, and deficiency of these critical proteins is the cause of hemophilia A and B, respectively. The fIXa-fVIIIa complex is known as intrinsic Xase and forms on the surface of activated platelets to efficiently produce fXa, resulting in a burst of thrombin formation.Regulatory proteins guard against overgrowth or dissemination of the clot, and all proteases generated in the cascade must eventually be inhibited. Factors VIIa and Xa are inhibited during the initiation phase by tissue factor pathway inhibitor (4), a triple Kunitz-domain canonical inhibitor, but the principal inhibitor of the coagulation proteases is the aptly named member of the serpin fam...