Background: Prior studies have proposed several electrocardiogram (ECG) criteria in limb leads for identifying the culprit coronary artery (CCA) in patients with acute inferior wall myocardial infarction (IWMI). The aim of our study was to conduct an evidence-based evaluation and test accuracy comparison of these criteria. Methods: We searched the PubMed, Embase, and Ovid. Eligible studies to assess the diagnostic performance of ECG criteria predicting CCA in IWMI were reviewed for inclusion. A diagnostic meta-analysis of bivariate approach was performed for pooled estimates of sensitivity and specificity, and meta-regression was implemented to investigate sources of heterogeneity. Results: Twenty-four studies with 4431 unique participants met the inclusion criteria. The pooled sensitivity and specificity for STsegment elevation (STE) in III>II, ST-segment depression (STD) in I, STD in aVL, STD in aVL>I, STE in III>II, and STD in aVL>I were 0.91 (0.88-0.94) and 0.69 (0.53-0.81), 0.80 (0.73-0.87) and 0.69 (0.62-0.76), 0.90 (0.81-0.95) and 0.41 (0.22-0.62), 0.84 (0.750.91) and 0.72 (0.48-0.88), and 0.79 (0.62-0.90) and 1.00 (0.37-1.00), respectively. Heterogeneity investigation showed that whether multi-vessel diseased patients were excluded, sample size, publication year, etc., could influence the diagnostic performance. Conclusion: STE in III > II performed better than other criteria for predicting RCA as CCA in IWMI, and STE in III > II and STD in aVL > I were potential and simple algorithms. ECG could be an effective tool to identify the CCA, but future studies are clearly needed to address the potential of diagnostic and prognostic value. Abbreviations: CAD = coronary artery disease, CAG = coronary angiography, CCA = culprit coronary artery, 95% confidence interval = 95% CI, ECG = electrocardiogram, IVUS = intravascular ultrasound, IWMI = inferior wall myocardial infarction, LAD = left anterior descending artery, LCX = left circumflex coronary artery, MI = myocardial infarction, PCI = percutaneous coronary intervention, RCA = right coronary artery, sROC = summary receiver operating characteristic, STD = ST-segment depression, STE = ST-segment elevation.