Background: Myocardial infarction (MI) is leading cause of death and disability globally. The electrocardiogram (ECG) is a critical component of the diagnostic workup for individuals with suspected MI. Electrocardiograms are essential in identifying the type and location of acute myocardial infarction. This study aimed to clarify the value of ECG for identification of the culprit artery in acute inferior STEMI with multivessel coronary artery disease. Patients and Methods: This study included 55 patients with acute inferior STEMI who were divided into two group based on the culprit coronary artery identification at time of PPCI, Electrocardiographic analysis was carried out to compare with angiographic findings that correlate with culprit artery location (either right coronary artery or left circumflex); Group I: Included 43 patients, (culprit was RCA), Group II: Included 12 patients, (culprit was LCX). Results: After comparing the findings in electrocardiographic leads, it was evident that the degree of ST segment deviation in leads II and V6 was statistically significantly higher in LCX group VS RCA group (1.9±0.8mm VS1.5±1.1mm, p-value=0.049 and 1.1±1.0VS -0.4±1.0 p-value <0.001 respectively). Also; the degree of ST segment deviation in leads aVL was statistically significantly higher in RCA group VS LCX group (-2.4±0.9mm VS -1.3±1.4mm, p-value=0.001). Conclusion: In patients with acute inferior STEMI and multivessel coronary artery disease where LCX is the IRA, presenting ECG is more likely to reflect less pronounced reciprocal ST depression in aVL and more marked STE in V6.