To characterize regional cardiac sympathetic dysfunction due to myocardial ischemia, we examined 123I-metaiodobenzylguanidine (MIBG) myocardial distribution of initial 15-min and 4-hr delayed SPECT images in 14 patients with recent myocardial infarction (MI), 25 patients with vasospastic angina which was angiographically proven with elgonovine maleate (Gp VSAP) and 16 patients with chest pain syndrome and normal CAG findings (GpCP). In those with MI, the study was serially done at 2 weeks after (Gp MI-1) and at 3 months after the onset of MI (Gp MI-2). We estimated regional tracer uptake in 20 segments of tomographic images by using a 4-point scoring system (0 = normal, 1 = mild, 2 = moderate, 3 = severe reduction) and calculated the total defect score (IDS). In all patients with MI, the area of reduced MIBG uptake was more extensive than the 201Tl perfusion defect in the acute stage (Gp MI-1) indicating the presence of viable but denervated myocardial tissue. Also, the MIBG defect was persistently observed from initial (TDS: 24 +/- 13) to delayed imaging (TDS: 26 +/- 12). However, in the chronic stage (Gp MI-2), the initial MIBG uptake improved (TDS: 18 +/- 9) but the delayed uptake remained almost the same (TDS: 22 +/- 10) indicating high washout of MIBG from the ischemic myocardium. Fourteen in Gp VSAP and 14 in Gp CP showed the regional MIBG defect in the delayed image more extensively than in the initial image indicating high washout of MIBG in the involved myocardial regions. These results suggest that neuronal uptake of MIBG is impaired in the acute stage of MI although neuronal retention of MIBG is predominantly impaired in the chronic stage of MI or in Gps VSAP and CP.