Although coronary angiography remains the gold standard, ECG can help to anticipate infarct related artery (IRA) before angiography, especially in hospitals which are not equipped with angiographic facilities. In this study Fiol’s algorithm was used to predict the stenosis/occlusion in coronary arteries of acute anterior and inferior wall MI. Invasive coronary angiography was done to identify the culprit coronary artery in al the study patients. In differentiating the site of lesion between RCA and LCx, ECG has high sensitivity (95.7%), positive predictive accuracy (96.6%) and negative predictive accuracy (96.4%) for RCA occlusions, and high specificity (98.2%), positive predictive accuracy (91%) and negative predictive accuracy (90%) for LCX lesions. There is a significant difference (p≤0.05) between RCA and LCx occlusion in ST segment displacements in Lead I, aVL, V1, V2, V3 and V6 leads (p<0.05). There is significant difference (p≤0.05) between proximal and distal RCA in ST–segment deviation in Lead I, aVF, V1, and V6 leads (p<0.01). In conclusion, ECG can help to localize culprit coronary artery in acute myocardial infarction prior to coronary angiography, especially in hospitals without angiography facilities.