BACKGROUND & OBJECTIVES The Electrocardiogram remains a crucial tool in the identification and management of acute myocardial infarction. A detailed analysis of patterns of ST-segment elevation may influence decisions regarding the perfusion therapy. This study was undertaken to identify the culprit vessel from ECG in patients with acute ST elevation myocardial infarction and correlate with coronary angiogram. MATERIALS & METHODS This is a prospective study, conducted on 126 patients in Osmania General Hospital, Hyderabad. Patients with ST segment elevation from ECG was evaluated to identify culprit vessel and later correlated with coronary angiogram. RESULTS Amongst 126 patients in this study, 70 patients had anterior wall and 56 patients had inferior wall myocardial infarction. ST> 1mm in V4R, ST V3/ST LIII Lead II was the most sensitive and ratio of STV3/STLIII >1.2 was the most specific criteria. ST in inferior leads > 1mm had maximum sensitivity in localizing occlusion in proximal D1 occlusion proximal to S1 as well. Absence of ST i in inferior leads is the most sensitive criteria in occlusion distal to S1 as well as in distal D1 in AWMI. CONCLUSION The admission ECG in patients with ST elevation AMI is valuable not only for determining early reperfusion treatment, but also provides important information to guide clinical decision-making.