Overweight and/or obesity at ACS presentation are associated with lower short-term risk of death. The obesity paradox may be a function of younger age at presentation, referral for angiography at an earlier stage of dis- ease, and more aggressive management of ACS.123 These indi- viduals, especially those with severe obesity (body mass index >35), have a higher long-term total mortality risk.124 129 Cocaine use can cause ACS by inducing coronary vaso- spasm, dissection, thrombosis, positive chronotropic and hypertensive actions, and direct myocardial toxicity (Section Methamphetamines are also associated with ACS.131 Urine toxicology screening should be considered when sub- stance abuse is suspected as a cause of or contributor to ACS, especially in younger patients (<50 years of age).132 3.3.2.3. Early Estimation of Risk The TIMI risk score is composed of 7, 1-point risk indicators rated on presentation (Table 3).42 The composite endpoints increase as the score increases. The TIMI risk score has been validated internally within the TIMI 11B trial and in 2 separate cohorts of patients from the ESSENCE (Efficacy and Safety of Subcutaneous Enoxaparin in Non Q-Wave Coronary The TIMI risk score calculator is available at www.timi.org. The TIMI risk index is useful in predicting 30-day and 1-year mortality in patients with NSTE-ACS.134 For patients with a TIMI risk score of 0 and normal high-sen- sitivity cardiac troponin 2 hours after presentation, accelerated diagnostic protocols have been developed that predict a very low rate of 30-day MACE (Section 3.4.3).65 The GRACE risk model predicts in-hospital and post- discharge mortality or MI.44,78,79,81 The GRACE tool was developed from 11389 patients in GRACE and validated in subsequent GRACE and GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) IIb cohorts. 