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Objective: To assess electrocardiogram (ECG) for risk stratification in inferior ST-elevation myocardial infarction (STEMI) patients within 24 h., Methods: Three hundred thirty-four patients were divided into four ECG-based groups: Group A: R V 1 <0.3 mV with ST-segment elevation (ST↑) V 7 -V 9 , Group B: R V 1 <0.3 mV without ST↑ V 7 -V 9 , Group C: R V 1 ≥0.3 mV with ST↑ V 7 -V 9 , and Group D: R V 1 ≥0.3 mV without ST↑ V 7 -V 9 ., Results: Group A demonstrated the longest QRS duration, followed by Groups B, C, and D. ECG signs for right ventricle (RV) infarction were more common in Groups A and B (p < .01). ST elevation in V 6 , indicative of left ventricle (LV) lateral injury, was more higher in Group C than in Group A, while the ∑ST↑ V 3 R + V 4 R + V 5 R, representing RV infarction, showed the opposite trend (p < .05). The estimated LV infarct size from ECG was similar between Groups A and C, yet Group A had higher creatine kinase MB isoform (CK-MB; p < .05). Cardiac troponin I (cTNI) was higher in Groups A and C than in B and D (p < .05 and p = .16, respectively). NT-proBNP decreased across groups (p = .20), with the highest left ventricular ejection fraction (LVEF) observed in Group D (p < .05). Group A notably demonstrated more cardiac dysfunction within 4 h post-onset., Conclusions: For inferior STEMI patients, concurrent R V 1 <0.3 mV with ST↑ V 7 -V 9 suggests prolonged ventricular activation and notable myocardial damage. RV infarction's dominance over LV lateral injury might explain these observations., (© 2024 The Authors. Annals of Noninvasive Electrocardiology published by Wiley Periodicals LLC.)