Cardiac 18F-dopamine positron emission tomography predicts the type of phenoconversion of pure autonomic failure

Purpose Pure autonomic failure (PAF) is a rare disease characterized by neurogenic orthostatic hypotension (nOH), no known secondary cause, and lack of a neurodegenerative movement or cognitive disorder. Clinically diagnosed PAF can evolve (“phenoconvert”) to a central Lewy body disease [LBD, e.g., Parkinson’s disease (PD) or dementia with Lewy bodies (DLB)] or to the non-LBD synucleinopathy multiple system atrophy (MSA). Since cardiac 18 F-dopamine-derived radioactivity usually is low in LBDs and usually is normal in MSA, we hypothesized that patients with PAF with low cardiac 18 F-dopamine-derived radioactivity would be more likely to phenoconvert to a central LBD than to MSA. Methods We reviewed data from all the patients seen at the National Institutes of Health Clinical Center from 1994 to 2023 with a clinical diagnosis of PAF and data about 18 F-dopamine positron emission tomography (PET). Results Nineteen patients (15 with low 18 F-dopamine-derived radioactivity, 4 with normal radioactivity) met the above criteria and had follow-up data. Nine (47%) phenoconverted to a central synucleinopathy over a mean of 6.6 years (range 1.5–18.8 years). All 6 patients with low cardiac 18 F-dopamine-derived radioactivity who phenoconverted during follow-up developed a central LBD, whereas none of 4 patients with consistently normal 18 F-dopamine PET phenoconverted to a central LBD ( p = 0.0048), 3 evolving to probable MSA and 1 upon autopsy having neither a LBD nor MSA. Conclusion Cardiac 18 F-dopamine PET can predict the type of phenoconversion of PAF. This capability could refine eligibility criteria for entry into disease-modification trials aimed at preventing evolution of PAF to symptomatic central LBDs.