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This review argues that the clinical and scientific value of cardiac sympathetic neuroimaging is broader than being merely confirmatory.\n                    <jats:sup>123<\/jats:sup>\n                    I\u2010metaiodobenzylguanidine (\n                    <jats:sup>123<\/jats:sup>\n                    I\u2010MIBG) single photon emission computed tomography (SPECT) is the practical clinical modality for detecting cardiac sympathetic denervation, whereas\n                    <jats:sup>18<\/jats:sup>\n                    F\u2010dopamine positron emission tomography (PET) also provides a pathophysiologic probe of sympathetic neuronal uptake, vesicular sequestration, and intra\u2010neuronal catecholamine metabolism. In autonomic synucleinopathies, this distinction is especially relevant for separating PD with orthostatic hypotension (PD\u2009+\u2009OH) from the parkinsonian form of multiple system atrophy (MSA\u2010P), for predicting phenoconversion in isolated neurogenic OH, for delineating specific intra\u2010neuronal functional abnormalities, and for stratifying patients for mechanism\u2010based treatment trials. Evidence from prospective longitudinal studies and computational modeling supports a body\u2010first pathway in some central Lewy body diseases, with cardiac noradrenergic deficiency preceding overt motor or cognitive manifestations. Cardiac sympathetic neuroimaging therefore may help move the field from clinical confirmation toward biomarker\u2010based diagnosis, prognostication, and preclinical intervention.\n                  <\/jats:p>","DOI":"10.1002\/mdc3.70722","type":"journal-article","created":{"date-parts":[[2026,7,6]],"date-time":"2026-07-06T13:56:38Z","timestamp":1783346198000},"page":"2395-2404","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cardiac Sympathetic Neuroimaging in Autonomic Synucleinopathies:\n                    <scp>\n                      <sup>123<\/sup>\n                      I\n                    <\/scp>\n                    \u2010Metaiodobenzylguanidine and\n                    <scp>\n                      <sup>18<\/sup>\n                      F\n                    <\/scp>\n                    \u2010Dopamine"],"prefix":"10.1002","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5709-9940","authenticated-orcid":false,"given":"David S.","family":"Goldstein","sequence":"first","affiliation":[{"name":"Clinical Neurosciences Program (CNP), Division of Intramural Research (DIR) National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH)  Bethesda Maryland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,7,6]]},"reference":[{"key":"e_1_2_9_2_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM198007173030304"},{"key":"e_1_2_9_3_1","doi-asserted-by":"publisher","DOI":"10.1126\/science.129.3357.1226"},{"key":"e_1_2_9_4_1","first-page":"1182","article-title":"Iodine\u2010123 metaiodobenzylguanidine imaging of the heart in idiopathic congestive cardiomyopathy and cardiac transplants","volume":"30","author":"Glowniak JV","year":"1989","journal-title":"J Nucl 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