ST- segment depression in lead aVR is a predictor for culprit artery in patients with inferior myocardial infarction. We assessed the utility of ST-segment depression in lead aVR in patients with inferior myocardial infarction. 100 patients with first time inferior STEMI were included in this study. According to ST-segment depression in lead aVR on admission ECG, patients were divided into two groups: Group I: No ST-segment depression. Group II: ST-segment depression ≥ 1mm. All patients underwent primary PCI. The culprit artery was RCA in 80% of all patients and LCX in 20%. In group I, 90% had RCA, and 10% had LCX as the culprit artery. In group II, 43% had RCA, and 57 % had LCX as the target vessel. There was strong correlation between the presence of ST- segment depression in lead aVR and the culprit artery (P =0.0001). The mean peak CK-MB was significantly higher in-group II (250.62 ± 119.79 u/l) than in group I (191.73 ± 76.19 u/l), P =0.007. In-Hospital mortality was higher in ST- segment depression group (14.3% vs 2.5%), P= 0.03. Patients with ST- segment depression have higher rate of killip class IV (14.3% vs 1.3%), P= 0.007. ST-segment depression in lead aVR predicted culprit artery occlusion with high sensitivity and specificity for LCX and was associated with larger infarction size and worse in hospital outcome.