Objective To explore the relationship of culprit artery lesion and clinical prognosis with different electrocardiogram(ECG) reciprocal ST segment depression(R-ST-D) types in patients with acute ST segment elevation myocardial infarction(STEMI). Methods Totally 967 cases of STEMI with completed data were enrolled in present study. The patients were then divided into four groups according to the amplitude of R-ST-D. GroupⅠconsisted of 143 patients with non R-ST-D; group Ⅱconsisted of 664 patients whose amplitude of R-ST-D were less or equal to the amplitude of the ST segment elevation in myocardial infarction area; group Ⅲ consisted of 93 patients whose amplitude of R-ST-D was larger than the amplitude of the ST segment elevation; group Ⅳ consisted of 67 patients whose corresponding ST segment and ST segment in myocardial infarction area were all elevated. The culprit artery lesion and clinical prognosis were compared between the four groups. Results The occurrence of R-ST-D were recorded, which were 14.8%, 68.7%, and 9.6% in group Ⅰ, Ⅱ, and Ⅲ, respectively, which mainly involved anterior descending branch. In group Ⅳ, the incidence was 6.9%, and it mainly involved complex anterior wall, anterior descending branch, circumflex branch, and right coronary artery. The prognosis indices included pump failure, low blood pressure, malignant arrhythmia, infarction extension, ventricular wall incoordination, left ventricular ejection fraction≤50%, and in-hospital mortality, which were 71.6%, 41.8%, 61.2%, 34.3%, 100.0%, 40.3%, and 16.4% respectively(P＜0.05 or P＜0.01). Conclusion Different ECG R-ST-D in patients with acute ST segment elevation myocardial infarction can forecast the culprit artery lesion and clinical prognosis.