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Background: It is proposed that among patients with chronic diseases including those with coronary artery disease, overweight is associated with survival advantage. Such phenomena is called the obesity paradox. Our aim was to investigate the relationship between body mass index and mortality among patients with acute coronary syndrome using national database. Methods: We queried the national inpatient sample size and identified all patients who were admitted with primary diagnosis acute coronary syndrome (NSTEMI or STEMI) during the period 2011 to 2014. All patients who had registered Body mass index (BMI) value where included. Patients were divided according to their BMI into ten BMI groups. Multivariate logistic regression analysis was performed to study the correlation between each BMI group and mortality. Results: Overall, 272,240 patients were identified. 56.3% were males and the mean age was 62.5±13.2 years. 44.8% of patients received PCI intervention and 12.3% received CABG. The in-hospital mortality rate was 3.3%. On multivariate logistic regression analysis, after adjusting for age, smoking, illness induced weight loss and baseline clinical characteristics, BMI 25-29 (OR:0.813, CI:0.752-0.880; p<0.001), BMI 30-34 (OR: 0.726, CI: 0.684 - 0.771; p<0.001) and BMI 35-39 (OR: 0.708, CI: 0.664 - 0.755; p<0.001) correlated with lowest mortality. BMI 19-24 (OR:1.234, CI: 1.144 - 1.331; p<0.001) and BMI 40-44 (OR: 1.213, CI: 1.145 - 1.284; p<0.001) correlated with higher mortality. BMI values within ranges lower than 19 or higher than 44 were similarly associated with higher mortality risk. (see figure) Conclusion: Among patients with ACS, the relationship between BMI and risk for mortality followed a U shape curve. BMI within range 25-39 had lowest risk for mortality. Both underweight and morbid obesity are independently associated with higher chance of mortality. [ABSTRACT FROM AUTHOR]