In a patient who is anticoagulated with heparin for a pulmonary embolism, how long must the heparin be continued after the international normalized ratio (INR) is greater than 2 for 24 hours?
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Current guidelines recommend starting unfractionated heparin (UFH) or a low molecular weight heparin (LMWH), in addition to an oral anticoagulant, at the time of pulmonary embolism diagnosis.
Initial treatment with UFH, LMWH, or fondaparinux must continue for at least 5 days and until the INR is greater than 2 for 24 hours. Warfarin should be started on the first treatment day.
Heparin treatment has to overlap with oral warfarin because there is a risk of transient hypercoagulable state induced by warfarin.
When intravenous heparin is started, the goal is to achieve a PTT of at least 1.5 times control. Heparin has a half-life of 60 to 75 minutes.
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