Thrombin is the ultimate protease of the blood clotting cascade and plays a major role in its own regulation. The ability of thrombin to exhibit both pro-and anti-coagulant properties has spawned efforts to turn thrombin into an anticoagulant for therapeutic purposes. This quest culminated in the identification of the E217K variant through scanning and saturation mutagenesis. The antithrombotic properties of E217K thrombin are derived from its inability to convert fibrinogen to a fibrin clot while maintaining its thrombomodulin-dependent ability to activate the anticoagulant protein C pathway. Here we describe the 2.5-Å crystal structure of human E217K thrombin, which displays a dramatic restructuring of the geometry of the active site. Of particular interest is the repositioning of Glu-192, which hydrogen bonds to the catalytic Ser-195 and which results in the complete occlusion of the active site and the destruction of the oxyanion hole. Substrate binding pockets are further blocked by residues previously implicated in thrombin allostery. We have concluded that the E217K mutation causes the allosteric inactivation of thrombin by destabilizing the Na ؉ binding site and that the structure thus may represent the Na ؉ -free, catalytically inert "slow" form.Thrombin activity is central to hemostasis, the balance between thrombosis and bleeding (for reviews, see Refs. 1, 2), and consequently thrombin is an important target of anticoagulant therapies (for review, see Ref.3). Thrombin is generated from its zymogen form, prothrombin, at the end of the coagulation cascade and is eventually inhibited by the circulating serpin antithrombin (for review, see Ref. 4). Thrombin has many procoagulant properties, including the cleavage of fibrinogen to fibrin, which then polymerizes to form the fibrin clot. Thrombin is also responsible for activating the transglutaminase factor XIII, which stabilizes the clot by cross-linking the fibrin polymers. Thrombin activates platelets by cleaving protease-activated receptors and stimulates its own generation by activating cofactors V and VIII. Hemostasis is dependent on limiting procoagulant activity to surfaces of the vasculature that have been compromised. Thus, when thrombin leaches away from the site of tissue damage its activity is reversed from pro-to anti-coagulant by binding to the integral membrane protein, thrombomodulin (TM), 1 expressed at the surface of the intact endothelium (5). Once bound to TM, thrombin can no longer cleave fibrinogen and instead cleaves protein C to yield activated protein C. Activated protein C then dampens thrombin generation by cleavage inactivation of cofactors Va and VIIIa (for review, see Ref. 6).Thrombin interacts with many cofactors capable of inducing conformational change and altered protease activity; however, the physiological significance of thrombin allostery is unclear (7-10). The most relevant alteration of thrombin activity is caused by its binding to TM, but similar changes can also be induced by other cofactors. Of particular interest...