Elsevier

Biomedicine & Pharmacotherapy
生物医学与药物治疗

Volume 149, May 2022, 112894
第 149 卷，2022 年 5 月，第 112894 号
Biomedicine & Pharmacotherapy

Review 评论
Development of vericiguat: The first soluble guanylate cyclase (sGC) stimulator launched for heart failure with reduced ejection fraction (HFrEF)
心衰射血分数降低（HFrEF）治疗领域首款可溶性鸟苷酸环化酶（sGC）激动剂——维立吉特的研发

https://doi.org/10.1016/j.biopha.2022.112894Get rights and content 获取权利和内容
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Highlights 高光内容

  • •
    The review summarizes the evolution of vericiguat, the first sGC stimulator approved for the treatment of patients with HFrEF.
    该综述总结了维立西格特的演变过程，这是首个获准用于治疗患有射血分数降低性心力衰竭（HFrEF）患者的 sGC 激动剂。
  • •
    For the first time, dual synthetic routes of vericiguat were elaborated and compared in a road map.
    首次，在路线图中详细阐述了 vericiguat 的两种合成路线，并进行了比较。
  • •
    The mechanism, pharmacology, clinical trials and ADMET of vericiguat were fully depicted.
    机制、药理学、临床试验和 ADMET 特性对 vericiguat 进行了全面描述。
  • •
    The development of new sGC stimulators and current GDMT for HFrEF patients are also discussed.
    新 sGC 激动剂的开发以及目前用于 HFrEF 患者的 GDMT 治疗方案也进行了讨论。

Abstract 摘要

In recent years, with improvements in treatments for heart failure (HF), the survival period of patients has been extended. However, the emergence of some patients with repeated hospitalizations due to their worsening conditions and low survival rates followed. Currently, few drugs are available for such patients. Vericiguat was first drug approved for the treatment of symptomatic patients with chronic HF with reduced ejection fraction (HFrEF) to reduce the occurrence of worsening HF. This article provides comprehensive information about vericiguat in terms of drug design and development, structure-activity relationship (SAR), synthesis, pharmacological efficacy, and clinical practice. In addition, insights into the current vericiguat trials and treatments of HF are also discussed.
近年来，随着心力衰竭（HF）治疗方法的改进，患者的生存期得到了延长。然而，一些患者因病情恶化而反复住院，生存率较低，这种情况也随之出现。目前，针对这类患者可用的药物很少。维利吉单抗是第一种获准用于治疗慢性心力衰竭（HFrEF）症状性患者的药物，旨在减少心力衰竭恶化的发生。本文全面介绍了维利吉单抗的药物设计、开发、结构-活性关系（SAR）、合成、药理效力和临床应用。此外，还讨论了当前维利吉单抗临床试验和心力衰竭治疗的情况。

Abbreviations 缩略语

ACEI
Angiotensin-converting enzyme inhibitor
血管紧张素转换酶抑制剂
ADME
Absorption, distribution, metabolism, excretion
吸收、分布、代谢、排泄
ARB ARB （请注意，"ARB" 可能是一个缩写或专有名词，没有上下文的情况下，直接翻译成中文可能没有实际意义。如果这是一个特定的缩写，请提供更多上下文以便准确翻译。）
Angiotensin II receptor blocker
血管紧张素 II 受体阻滞剂
AUC
Area under the drug time curve
药物时间曲线下面积
BP BP BP
Blood pressure 血压
CAD CAD 计算机辅助设计
Coronary artery disease 冠状动脉疾病
CAT 猫
Catalytic 催化
CC CC ## 翻译要求： 1. 确保忠实于“源文本”，确保每句话的翻译准确流畅。 2. 确保在翻译过程中不遗漏任何部分，每个细节都必须包含。 3. 大数字必须按照简体中文规范正确翻译。 ## 指示： 1. 仔细分析和深入理解“源文本”的内容、语境、情感和文化细微差别，与目标语言相关。 2. 根据翻译要求，将“源文本”准确翻译成简体中文。 3. 确保翻译准确、自然、流畅，适合目标受众。根据文化语言规范调整表达。 ## 要求： 不包含任何额外内容。仅输出翻译。这是至关重要的
Coiled coil 螺旋状
CI CI CI
Confidence interval 置信区间
CLb
Blood clearance 血液清除
cGMP
Cyclic guanosine monophosphate
环状鸟苷单磷酸
Cmax
Maximum blood concentration
最大血药浓度
CYP CYP （请注意，"CYP" 可能代表不同的含义，如国家代码、组织名称或缩写。由于缺乏具体上下文，以下提供几种可能的翻译：） 1. 塞浦路斯 2. 某组织/机构的缩写 3. 某产品/服务的缩写
Cytochrome P450 细胞色素 P450
EC50 = 5.5 EC 50 = 5.5 EC 50 等于 5.5
Concentration for 50% of maximal effect
50%最大效应的浓度
FDA 美国食品药品监督管理局
Food and Drug Administration
食品药品监督管理局
GDMT
Guideline-directed medical therapy
指导性药物治疗
GTP
Guanosine triphosphate 鸟苷三磷酸
HF HF ## 翻译要求： 1. 确保翻译忠实于“源文本”，确保每句话的翻译准确流畅。 2. 确保在翻译过程中不遗漏任何部分，每个细节都必须包含。 3. 大数字必须按照简体中文规范正确翻译。 ## 指示： 1. 仔细分析和深入理解“源文本”的内容、语境、情感和文化细微差别，与目标语言相关。 2. 根据翻译要求，将“源文本”准确翻译成简体中文。 3. 确保翻译准确、自然、流畅，适合目标受众。根据文化语言规范调整表达。 ## 要求： 不包含任何额外内容。仅输出翻译。这是至关重要的
Heart failure 心力衰竭
HFpEF HFpEF 高福平效应
Heart failure with preserved ejection fraction
心力衰竭（射血分数正常）
HFrEF
Heart failure with reduced ejection fraction
心功能不全（射血分数降低）
H-NOX
N-terminal haem nitric oxide
N-端血红素一氧化氮
HR 人力资源
Hazard ratio 危害比
IC50 """ IC 50 """ ## Simplified Chinese Translation: """ IC 50 """
50% Inhibitory concentration
50% 抑制浓度
ISMN
Isosorbide mononitrate 异山梨酯硝酸盐
KCCQ
Kansas City Cardiomyopathy Questionnaire
堪萨斯城心肌病问卷
LVEF 左心室射血分数
Left ventricular ejection fraction
左心室射血分数
MEC
Minimum effective concentration
最小有效浓度
MRA
Mineralocorticoid receptor antagonist
矿物皮质激素受体拮抗剂
NO 不
Nitric oxide 一氧化氮
NT-proBNP
N-terminal pro-B-type natriuretic peptide
N-末端 B 型利钠肽
PAS
Per-ARNT-Sim Per-ARNT-Sim 佩-ARNT-模拟
PDE 偏微分方程
Phosphodiesterase 磷酸二酯酶
PLS 请
Physical limitation score
身体限制评分
q.d. q.d. 请提供上下文或更多信息，以便进行准确的翻译。
Quaque die, once a day
每天一次
RAAS RAAS （请注意，"RAAS" 可能是一个缩写或专有名词，没有上下文的情况下，直接翻译成中文可能无法准确传达其含义。如果这是一个特定的术语或缩写，建议提供更多背景信息以便进行准确的翻译。）
Renin-angiotensin-aldosterone system
肾素-血管紧张素-醛固酮系统
SAR
Structure-activity relationship
结构-活性关系
sGC sGC sGC
Soluble guanylate cyclase
可溶性鸟苷酸环化酶
SGLT2
Sodium-glucose transport protein 2
钠-葡萄糖转运蛋白 2
TFA
Trifluoroacetic acid 三氟乙酸
UDPGA
Uridine diphosphate glucuronic acid
尿苷二磷酸葡萄糖醛酸
WHO WHO 谁
World Health Organization
世界卫生组织

Keywords 关键词

Drug discovery
Heart failure (HF)
Structure-activity relationship (SAR)
Soluble guanylate cyclase (sGC) stimulator
Vericiguat

药物发现 心力衰竭（HF） 结构-活性关系（SAR） 可溶性鸟苷酸环化酶（sGC）激动剂 维利吉尤特

1. Introduction 1. 引言

Heart failure (HF) refers to the inability of the heart to pump enough blood to sustain the body’s metabolism [1], [2], and the main manifestations are dyspnoea, fatigue and fluid retention [3]. There are more than 64 million HF patients worldwide [4], and this condition is on the rise due to the ageing of the population and the increased prevalence of obesity [5]. Other common triggers include sex, coronary artery disease (CAD), excessive drinking, etc. [6], [7], [8], [9]. HF has long been described as a “stumbling block in life”, side by side with malignant tumours [10]. HF imposes an extremely heavy economic burden worldwide of approximately $108 billion per year [11], [12]. The phenotype of HF with reduced ejection fraction (HFrEF) is more important, accounting for approximately 40–50% of cases, and shows a very high rate of exacerbation and mortality.
心力衰竭（HF）是指心脏无法泵出足够的血液以维持身体的新陈代谢[1][2]，其主要症状包括呼吸困难、疲劳和水肿[3]。全球有超过 6400 万心力衰竭患者[4]，由于人口老龄化和肥胖症的普遍增加，这种状况正在上升[5]。其他常见诱因包括性别、冠状动脉疾病（CAD）、过量饮酒等[6][7][8][9]。心力衰竭长期以来被描述为“生活中的绊脚石”，与恶性肿瘤并列[10]。心力衰竭对全球造成了约 1080 亿美元的经济负担[11][12]。射血分数降低的心力衰竭（HFrEF）表型更为重要，约占病例的 40-50%，且其恶化率和死亡率非常高。
As shown in Fig. 1, drug therapy remains an important cornerstone of HFrEF. In the more than 200 years since digitalis inotropes were first used for HFrEF treatment in 1785, drugs with new mechanisms have been developed one after another to expand patients’ medication options, stabilize or alleviate patients’ conditions, and reduce mortality [13], [14], [15], [16], [17], [18]. However, HFrEF is a chronic disease, even with guideline-directed medical therapy developed by different national cardiology societies, including β-blockers and renin-angiotensin system inhibitors (ACEIs/ARBs/ARNIs) [19], [20], [21], [22]. Up to 25% of patients with HFrEF are still at high risk of residual symptoms and worsening. For such a group, which is at high risk and in urgent need of new treatment, there are no medical options other than surgery. Therefore, the launch of the sGC stimulator vericiguat (CAS No: 1350653-20-1, Fig. 2), developed by Bayer and Merck after passing priority review, is undoubtedly exciting. Vericiguat will fill in the above gap and be given to symptomatic chronic HFrEF patients to reduce the risk of cardiovascular death and HF rehospitalization following hospitalization for HF or the need for diuretics in adult outpatients; moreover, it is expected to be the first drug to change the course of HFrEF [23], [24].
如图 1 所示，药物治疗仍然是 HFrEF 的重要基石。自 1785 年首次使用洋地黄强心剂治疗 HFrEF 以来，已有 200 多年，不断有具有新机制的药物被开发出来，以扩大患者的用药选择，稳定或缓解患者的病情，并降低死亡率[13]，[14]，[15]，[16]，[17]，[18]。然而，HFrEF 是一种慢性疾病，即使在不同国家心脏病学会制定的指南指导下，包括β受体阻滞剂和肾素-血管紧张素系统抑制剂（ACEIs/ARBs/ARNIs）[19]，[20]，[21]，[22]的药物治疗下，高达 25%的 HFrEF 患者仍然存在残余症状加重的风险。对于这一高风险且迫切需要新疗法的群体，除了手术外，没有其他医疗选择。因此，拜耳和默克公司开发的 sGC 激动剂 vericiguat（化学文摘号：1350653-20-1，图 2）在通过优先审查后上市，无疑令人兴奋。 Vericiguat 将填补上述空白，并用于治疗症状性慢性 HFrEF 患者，以降低在 HF 住院或成人门诊患者需要利尿剂后心血管死亡和 HF 再住院的风险；此外，它有望成为第一个改变 HFrEF 进程的药物[23]，[24]。
Fig. 1
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Fig. 1. Development of HFrEF drugs.
图 1. HFrEF 药物的研发。

Fig. 2
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Fig. 2. Molecular structure of vericiguat.
图 2. vericiguat 的分子结构。

2. Mechanism of vericiguat
2. 超级依格列净的作用机制

The nitric oxide (NO)-sGC-cyclic guanosine monophosphate (cGMP) axis has a crucial effect on the regulation of the cardiovascular system [25], [26], [27]. As early as 1879, the exogenous NO drug nitroglycerine was used to treat angina pectoris [28]. However, due to its high first-pass metabolism, low half-life and nonspecific effects, the clinical application of nitroglycerine is limited [29]. In subsequent years, inhibiting the activity of phosphodiesterase (PDE) downstream of cGMP has become a new strategy in which sildenafil drugs have been used [30], [31]. However, this pathway inhibits degradation only at the end; when NO is low, this approach is obviously limited. Finally, researchers focused their attention on the only known NO receptor, sGC, and began looking for targeted drugs [32], [33].
硝酸盐一 sGC-环状鸟苷酸单磷酸（cGMP）轴对心血管系统的调节起着至关重要的作用[25][26][27]。早在 1879 年，外源性一氧化氮药物硝酸甘油就被用于治疗心绞痛[28]。然而，由于其高首过代谢、半衰期短以及非特异性作用，硝酸甘油的临床应用受到限制[29]。在随后的几年里，抑制 cGMP 下游的磷酸二酯酶（PDE）活性成为了一种新的策略，其中已经使用了西地那非类药物[30][31]。然而，这种途径仅抑制降解的末端；当一氧化氮水平低时，这种方法显然有限。最后，研究人员将注意力集中在唯一已知的一氧化氮受体 sGC 上，并开始寻找靶向药物[32][33]。
sGC is composed of two homologous α and β subunits [34], [35], [36], [37], [38]. Each sGC subunit is made up of four domains: a central Per-ARNT-Sim (PAS) domain, an N-terminal haem nitric oxide (H-NOX) domain, a catalytic (CAT) cyclase domain and a coiled-coil (CC) domain [39], [40], [41]. When sGC forms its holoenzyme but is not yet activated, the overall structure is relatively compact, and the CC domain is curved [42]. When NO in the body binds to haem, the H-NOX domain of the β subunit and the entire protein are partially stretched. At this time, there is a dynamic balance between the extended and inactive states so that sGC is partially activated. Guanosine triphosphate (GTP) is also converted into cGMP in small amounts [43]. As a second messenger, cGMP can regulate vascular tone, cardiac remodelling and myocardial contractility by itself or by acting on multiple downstream targets, such as PDE. However, how cGMP acts downstream is not yet clear [44], [45], [46], [47]. Under pathological conditions, haem can be oxidized to a trivalent state, causing sGC to lose the ability to bind NO. Concurrently, the affinity of haem to sGC is weak and easy to disrupt.
sGC 由两个同源的α和β亚基组成[34]，[35]，[36]，[37]，[38]。每个 sGC 亚基由四个结构域组成：一个中央的 Per-ARNT-Sim（PAS）结构域，一个 N 端的血红素一氧化氮（H-NOX）结构域，一个催化（CAT）环化酶结构域和一个螺旋-螺旋（CC）结构域[39]，[40]，[41]。当 sGC 形成其全酶但尚未激活时，整体结构相对紧凑，CC 结构域呈弯曲状[42]。当体内的 NO 与血红素结合时，β亚基的 H-NOX 结构域和整个蛋白质部分伸展。此时，伸展和未激活状态之间存在动态平衡，使得 sGC 部分激活。同时，少量鸟苷三磷酸（GTP）也转化为 cGMP[43]。作为第二信使，cGMP 可以单独或通过作用于多个下游靶点（如 PDE）来调节血管张力、心脏重塑和心肌收缩力。然而，cGMP 在下游如何发挥作用尚不清楚[44]，[45]，[46]，[47]。在病理条件下，血红素可以被氧化成三价状态，导致 sGC 失去结合 NO 的能力。同时，血红素对 sGC 的亲和力减弱，易于被破坏。
To date, a large number of compounds have been derived to enhance the activity of sGC. In 2009, the World Health Organization (WHO) uniformly added the suffix "-ciguat" to all such compounds. These compounds are classified as activators or stimulators. The activators can bind to sGC with or without haem and activate it directly, which is suitable when sGC function is impaired by oxidation. The other type can be combined with sGC containing haem, and are called stimulators when acting synergistically with NO, which is suitable for use when sGC has normal function but the concentration of NO is low. Vericiguat is a stimulator. As shown in Fig. 3, vericiguat can achieve dual activation of sGC through autocatalysis and synergy with NO.
截至目前，已经衍生出大量化合物以增强 sGC 的活性。2009 年，世界卫生组织（WHO）统一将这些化合物后缀命名为“-西加”。这些化合物被归类为激活剂或刺激剂。激活剂可以与 sGC 结合，无论是否含有血红素，并直接激活它，这在 sGC 功能因氧化受损时适用。另一种类型可以与含有血红素的 sGC 结合，当与 NO 协同作用时称为刺激剂，这在 sGC 功能正常但 NO 浓度低时适用。维立西格为刺激剂。如图 3 所示，维立西格可以通过自催化和与 NO 的协同作用实现 sGC 的双重激活。
Fig. 3
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Fig. 3. Vericiguat acts on the NO-sGC-cGMP pathway.
图 3. 维立瓜特作用于 NO-sGC-cGMP 通路。

3. Soluble guanylate cyclase stimulator development and SAR study
3. 可溶性鸟苷酸环化酶激动剂的开发与 SAR 研究

3.1. Development of vericiguat
3.1. 乙酰半胱氨酸的开发

3.1.1. From YC-1 to riociguat
3.1.1. 从 YC-1 到瑞戈非布

In 1994, Bayer began a search for drugs that could target sGC [48]. The sGC-inducing activity of nearly 20,000 compounds was tested in primary endothelial cell cultures, and it was found that 5-substituted-2-furaldehyde-hydrazone derivatives could directly act on sGC and increase cGMP production [49]. In the same year, researchers from National Taiwan University and Yongshan Pharmaceuticals discovered that a benzyl indazole compound synthesized in 1978 for antithrombotic therapy could stimulate cGMP; they named this compound YC-1 [50].
1994 年，拜耳公司开始寻找能够靶向 sGC 的药物[48]。在初级内皮细胞培养中测试了近 20000 种化合物的 sGC 诱导活性，发现 5-取代-2-糠醛腙衍生物可以直接作用于 sGC 并增加 cGMP 的产生[49]。同年，来自台湾大学和永山制药的研究人员发现，1978 年合成用于抗血栓治疗的苄基吲哚化合物可以刺激 cGMP 的产生；他们将这种化合物命名为 YC-1[50]。
Lei Chen et al. performed molecular docking between YC-1 and NO-activated sGC (PDB ID: 6JT2), and the results showed that the compound mainly acts on β subunits sandwiched between β H-NOX and CC domains [51]. This also further verified the effect of vericiguat on sGC at the molecular level (Fig. 4). Specifically, including stacking of the side chain of β TYR112 with the terminal benzene ring of YC-1, vericiguat also forms hydrophobic interactions with the side chains of TYR2, PHE4 and haem. The central indazole part of YC-1 interacts with TYR83 and PHE77 in the H-NOX domain. The furan group of YC-1 interacts with β ARG40.
陈磊等人对 YC-1 与 NO 激活的 sGC（PDB ID：6JT2）进行了分子对接，结果显示该化合物主要作用于位于β H-NOX 和 CC 结构域之间的β亚基[51]。这也进一步验证了 vericiguat 在分子水平上对 sGC 的作用（图 4）。具体来说，包括β TYR112 侧链与 YC-1 端基苯环的堆积，vericiguat 还与 TYR2、PHE4 和血红素的侧链形成疏水相互作用。YC-1 的中央吲哚部分与 H-NOX 结构域中的 TYR83 和 PHE77 相互作用。YC-1 的呋喃基团与β ARG40 相互作用。
Fig. 4
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Fig. 4. The interactions between YC-1 and sGC (α and β homologous subunits and residues are shown in yellow and blue, respectively). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
图 4. YC-1 与 sGC（α和β同源亚基及残基分别用黄色和蓝色表示）之间的相互作用。（关于本图例中颜色引用的解释，请参阅本文的网页版。）

The above two compounds, with obvious structural similarity, were the starting point for the development of sGC drugs [52], [53]. Unfortunately, because of their poor vasodilation effects, low selectivity for PDE, and increased in vitro potency after exposure to light, the abovementioned compounds have not been further clinically developed [54], [55], [56]. Subsequently, CFM-1571 was produced, but its sGC-stimulating activity (concentration required for 50% of maximal effect, EC50 =5.5 μM) and oral bioavailability were relatively low (12%) [57]. In addition to the aminopyrimidine compounds shown in blue, early sGC stimulators also included arylacrylamides (shown in orange). However, this class of compounds was mainly focused on enhancing erectile function, so it is not discussed here [58], [59], [60].
上述两种具有明显结构相似性的化合物，是 sGC 药物开发的起点[52][53]。遗憾的是，由于它们的血管舒张效果不佳、对 PDE 的选择性低以及在光照下体外活性增强，上述化合物未能进一步进行临床开发[54][55][56]。随后，生产出了 CFM-1571，但其 sGC 刺激活性（产生最大效应 50%所需的浓度，EC50=5.5 μM）和口服生物利用度相对较低（12%）[57]。除了图中用蓝色表示的氨基嘧啶化合物外，早期的 sGC 激动剂还包括芳基丙烯酰胺（用橙色表示）。然而，这类化合物主要关注增强勃起功能，因此在此不予讨论[58][59][60]。
Notably, Bayer's research on sGC stimulators did not stop there. To develop next-generation stimulators, Bayer chemically optimized 2000 newly synthesized compounds to obtain BAY 41–2272, which was modified by substituting the benzyl indazole moiety of YC-1 with (2-fluorobenzyl) pyrazolopyridine and replacing the (hydroxymethyl) furan moiety with 5-substituted 4-aminopyrimidine [61], [62]. Compared with YC-1, BAY 41–2272 had higher stimulating potency and selectivity for sGC. However, BAY 41–2272 is clinically limited due to its strong inhibitory and inducing effects on cytochrome P450 (CYP) enzymes [63], [64].
值得注意的是，拜耳公司在 sGC 激动剂的研究并未止步于此。为了开发下一代激动剂，拜耳化学优化了 2000 种新合成的化合物，最终获得了 BAY 41-2272。该化合物通过将 YC-1 中的苄基吲哚基团替换为(2-氟苄基)吡唑吡啶，并将(羟甲基)呋喃基团替换为 5-取代的 4-氨基嘧啶来改性[61]，[62]。与 YC-1 相比，BAY 41-2272 具有更高的刺激活性和对 sGC 的选择性。然而，由于 BAY 41-2272 对细胞色素 P450（CYP）酶具有强烈的抑制和诱导作用[63]，[64]，其在临床应用上受到限制。
The pyrimidine ring of BAY 41–2272 was further modified to obtain a stronger sGC-stimulating effect and the specific 4,6-diamino-5-morpholine derivative BAY 41–8543 [65]. However, further clinical use of BAY 41–8543 was also hindered due to the high blood clearance (CLb) and the effect of dose nonlinearity [66]. After structure-activity relationship (SAR) analyses, researchers found that the above two problems were mainly concentrated at the C5 position on the pyrimidine ring. To further develop sGC drugs, Bayer began to further screen and optimize pyrimidine derivatives and finally identified BAY 63–2521 (riociguat) from the screening of over 1000 compounds (Fig. 5). Riociguat exhibited good metabolic stability and oral bioavailability and caused no CYP side effects [67], [68], [69]. BAY41–2272, BAY41–8543 and riociguat all combine with sGC in a manner similar to that of YC-1. The newly introduced diaminopyrimidine group produces additional polar interactions with β SER81 and VAL39, making riociguat more potent than YC-1 (Fig. 6).
BAY 41-2272 的嘧啶环经过进一步改造，以获得更强的 sGC 刺激效果，并最终得到了特定的 4,6-二氨基-5-吗啉衍生物 BAY 41-8543 [65]。然而，由于血清除率（CL b ）高和剂量非线性效应，BAY 41-8543 的临床应用也受到了阻碍 [66]。经过结构-活性关系（SAR）分析，研究人员发现上述两个问题主要集中在嘧啶环的 C5 位。为了进一步开发 sGC 药物，拜耳公司开始进一步筛选和优化嘧啶衍生物，并最终从超过 1000 个化合物的筛选中确定了 BAY 63-2521（利奥西格 uate）（图 5）。利奥西格 uate 表现出良好的代谢稳定性和口服生物利用度，并且不会引起 CYP 副作用 [67]，[68]，[69]。BAY41-2272、BAY41-8543 和利奥西格 uate 都与 sGC 以类似于 YC-1 的方式结合。新引入的二氨基嘧啶基团与β SER81 和 VAL39 产生额外的极性相互作用，使利奥西格 uate 比 YC-1 更有效（图 6）。
Fig. 5
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Fig. 5. Discovery of riociguat.
图 5. riociguat 的发现

Fig. 6
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Fig. 6. Combination of riociguat and sGC.
图 6. 肼碘苯甲酸与 sGC 的联合使用。

3.1.2. From riociguat to vericiguat
3.1.2. 从瑞戈非亚到维戈非亚

Although riociguat had a satisfactory sGC-stimulating effect, clinical studies of HF treatment showed that its half-life was short [70]. A series of structural optimizations of riociguat to reduce the CLb and increase the half-life led to the development of vericiguat (BAY 102-1189, MK-1242) [63]. As shown in Fig. 7, the modification process involved carbamate optimization and central skeleton replacement) .
尽管 riociguat 具有令人满意的 sGC 刺激作用，但针对 HF 治疗的临床研究表明其半衰期较短[70]。通过对 riociguat 进行一系列结构优化以降低 CL b 并延长半衰期，导致了 vericiguat（BAY 102-1189，MK-1242）的开发[63]。如图 7 所示，该改良过程涉及羧酸酯优化和核心骨架替换。
Fig. 7
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Fig. 7. The evolution of riociguat to vericiguat.
图 7. 里奥西古特向维里西古特的演变。

Fig. 8
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Fig. 8. Design strategy, chemical structure, MEC and CLb for carbamate optimization.
图 8. 羰基甲酸酯优化设计策略、化学结构、MEC 和 CL b 。

3.1.3. Carbamate optimization
3.1.3. 胺类化合物优化

To ensure the effect of riociguat (minimum effective concentration (MEC)= 0.03 µM) and increase its CLb from 0.2 L/h/kg, structural optimization of the 5-carbamate on the pyrimidine ring was first performed [71]. Compounds 1a-1 g were carbamates with 7 different N-substituents. As a result, the introduction of ethyl groups (1a), hydroxyethyl groups (1b), blocking group fluorine atoms (1c–d), and fluorobenzyl compounds (1e–f) failed to improve CLb Fig. 8.
为确保里奥西古特的效应（最小有效浓度（MEC）为 0.03 µM）并提高其在 0.2 L/h/kg 的清除率（CL b ），首先对嘧啶环上的 5-羰基进行了结构优化[71]。化合物 1a-1g 具有 7 种不同的 N-取代基。结果，引入乙基（1a）、羟乙基（1b）、阻断基氟原子（1c–d）和氟苯基化合物（1e–f）未能改善 CL b （图 8）。
In 2015, researchers discovered compound 2a with reduced CLb among the metabolites of riociguat [72], [73], [74], [75], [76]. To improve the stability, structural modification was conducted for the terminal methyl group, while the N remained unsubstituted. These research ideas are similar to those of compounds 1a-1 g, including the introduction of increased steric hindrance (2b–d) and the groups that could change metabolism (2e–f), but the results were not satisfactory [77], [78]. Notably, the stimulating effect of compound 2d (MEC=2.3 µM) on sGC is nearly 8 times higher than that of 2a, but due to its low ability to permeate the Caco-2 cell monolayer and high outflow rate (74), 2d was not further developed.
2015 年，研究人员在里奥古拉特（riociguat）的代谢物中发现了具有降低 CL b 的化合物 2a [72]，[73]，[74]，[75]，[76]。为了提高稳定性，对末端甲基基团进行了结构改造，而 N 基团则未进行取代。这些研究思路与化合物 1a-1g 类似，包括引入增加的位阻（2b–d）和可能改变代谢的基团（2e–f），但结果并不令人满意 [77]，[78]。值得注意的是，化合物 2d（MEC=2.3 µM）对 sGC 的刺激作用比 2a 高近 8 倍，但由于其渗透 Caco-2 细胞单层的低能力和高流出率（74），2d 并未进一步开发。
Finally, a series of compounds in which oxazolidinone (3a–c) derivatives replace carbamates have also been studied, but they were also ineffective with respect to in vitro clearance [79]. Since then, research on the optimization of carbamate groups has been halted. Therefore, the focus of the optimization shifted from carbamate to the central skeleton based on the most promising compound: N-unsubstituted carbamate 2a.
最后，一系列以氧杂唑啉酮（3a–c）衍生物取代脒基的化合物也被研究过，但在体外清除率方面同样无效[79]。从那时起，对脒基优化研究已经停止。因此，优化的重点从脒基转移到了基于最有希望的化合物 N-未取代脒基 2a 的中央骨架。

3.1.4. Central skeleton replacement
3.1.4. 核心骨架替换

The in vitro CLb values of the 6 compounds (4a–b) obtained by replacing the central skeleton were all ≤ 0.1 L/h/kg [80]. Fig. 9 shows the in vivo CLb in rats. 4a–b are adjustments to the pyrazole structure, of which 4a exhibited a significant increase in sGC stimulating activity (MEC=1.2 µM); however, it was rapidly metabolized. The 6-fluoro derivative 4b also had good sGC-stimulating ability and low CLb and was thus a good candidate. However, through metabolic studies, it was found that pyridine was not metabolized. To continue to pursue the discovery of a better structure, 1H-pyrazolo[3,4-c] pyridazine 4c, imidazo[1,5-a] pyrimidine 4d, imidazo[1,5-b] pyridazine 4e and 1H-pyrazolo [3,4-b] pyridine vericiguat derivatives were synthesized. Finally, a further cross-species study was carried out on the three preferred compounds, 4b, 4e, and vericiguat, with riociguat. The results showed that vericiguat had the best overall pharmacokinetic characteristics. Vericiguat had low CLb in rats and dogs, a long half-life, and high oral bioavailability. The half-life of vericiguat in patients was 30 h.
体外清除率（CL） b 的 6 个化合物（4a–b）在替换中心骨架后均≤0.1 L/h/kg [80]。图 9 展示了大鼠体内的清除率 b 。4a–b 是对吡唑结构的调整，其中 4a 表现出显著的 sGC 刺激活性（EC50=1.2 µM）；然而，它被迅速代谢。6-氟衍生物 4b 也具有良好的 sGC 刺激活性，且 CL b 低，因此是一个很好的候选者。然而，通过代谢研究，发现吡啶没有被代谢。为了继续追求更好的结构发现，合成了 1H-吡唑[3,4-c]吡啶氮杂环丁烷 4c、咪唑[1,5-a]嘧啶 4d、咪唑[1,5-b]吡啶 4e 和 1H-吡唑[3,4-b]吡啶 vericiguat 衍生物。最后，对三个优选化合物 4b、4e 和 vericiguat 与 riociguat 进行了进一步的多物种研究。结果显示，vericiguat 具有最佳的总体药代动力学特征。vericiguat 在大鼠和狗体内的 CL b 低，半衰期长，口服生物利用度高。vericiguat 在患者体内的半衰期为 30 小时。
Fig. 9
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Fig. 9. Riociguat central skeleton changes.
图 9. Riociguat 中心骨架变化。

As shown in Fig. 10, during the optimization process from riociguat to vericiguat, we found that the pink-shaded central skeleton of vericiguat is the core of its sGC-stimulating property and prolonged metabolism. 1H-indazole, 1H-benzopyrazole, imidazo[1,5-b]pyridazine 4e and 1H-pyrazolo[3,4-b]pyridine are all preferred backbone fragments. Another fragment that can be modified in this class of compounds is the purple-shaded carbamate moiety. The introduction of polar fragments to this structure to reduce lipid solubility and the introduction of F atoms to block metabolic sites and increase steric hindrance could slightly improve sGC activity but had few or even adverse effects on reducing clearance. At the same time, ensuring that the N atom on the carbamate is not substituted and that the terminal methyl group is unchanged can delay metabolism.
如图 10 所示，在从 riociguat 优化到 vericiguat 的过程中，我们发现 vericiguat 的粉红色阴影中心骨架是其 sGC 刺激性和延长代谢的核心。1H-吲哚、1H-苯并吡唑、咪唑并[1,5-b]吡啶 4e 和 1H-吡唑并[3,4-b]吡啶都是首选的骨架片段。在这类化合物中，还可以修改紫色阴影的碳酸酯基团。向该结构引入极性片段以降低脂溶性，以及引入 F 原子以阻断代谢位点并增加立体阻碍，可以略微提高 sGC 活性，但对降低清除率的影响很小甚至有不良反应。同时，确保碳酸酯上的 N 原子不被取代，以及末端的甲基基团保持不变，可以延缓代谢。
Fig. 10
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Fig. 10. SAR for vericiguat.
图 10. 超级依维古特的合成孔径雷达（SAR）图像。

3.2. Synthesis of vericiguat
3.2. vericiguat 的合成

The synthesis of vericiguat can be classified into two routes, which are outlined in Fig. 11.
图 11 概述了合成维立古阿的两种途径。
Fig. 11
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Fig. 11. Diagram of vericiguat synthesis3.2.2. Route 2.
图 11. vericiguat 合成路线 2 的示意图。

3.2.1. Route 1 3.2.1. 路线 1

Partial hydrolysis of 2,6-dichloro-5-fluoronicotinonitrile (5) with H2SO4 at 63 °C yields 2,6-dichloro-5-fluoronicotinamide (6), which upon partial dechlorination using Zn and AcOH in MeOH yields 2-chloro-5-fluoronicotinamide (7). The dehydration of intermediate (7) by means of (CF3CO)2O and Et3N in CH2Cl2 provides 2-chloro-5-fluoronicotinonitrile (8), which upon cyclization with N2H4·H2O in refluxing 1,2-ethanediol leads to 5-fluoropyrazolo[3,4-b] pyridin-3-amine (9). The diazotization of intermediate (9) with isoamyl nitrite and BF3·Et2O in THF, followed by iodination with NaI in acetone, provides 5-fluoro-3-iodopyrazolo[3,4-b] pyridine (10), which is then N-alkylated with 2-fluorobenzyl bromide (11) in the presence of Cs2CO3 in dimethylformamide (DMF) to yield 5-fluoro-1-(2-fluorobenzyl)-3-iodopyrazolo[3,4-b] pyridine (12). The reaction of intermediate (12) with (Bu3Sn)2, followed by Stille coupling with 2-chloro-5-nitropyrimidine-4,6-diamine (13) in the presence of Pd (PPh3)4 in refluxing dioxane affords intermediate (14). Nitro reduction of intermediate (14) with H2 over Pd/C in pyridine yields the triaminopyrimidine derivative (15), which is finally condensed with methyl chloroformate (16) in pyridine/CH2Cl2 to afford the vericiguat[81], [82]. The synthesis of intermediate (13) involves the initial nitration of 6-aminouracil (17) with HNO3, yielding 6-amino-5-nitrouracil (18), which upon chlorination with POCl3 and PhNMe2 yields 2,6-dichloro-5-nitropyrimidin-4-amine (19). The amination of intermediate (14) with ethanolic NH3 in ether provides 2-chloro-5-nitropyrimidine-4,6-diamine (13) [83].
部分水解 2,6-二氯-5-氟烟腈（5）在 63°C 下与 H2O2 和 SO2 反应，得到 2,6-二氯-5-氟烟酰胺（6），随后使用 Zn 和 AcOH 在 MeOH 中进行部分脱氯，得到 2-氯-5-氟烟酰胺（7）。通过(CF3CO)2O 和 Et3N 在 CH2Cl2 中进行脱水，得到 2-氯-5-氟烟腈（8），随后在回流 1,2-乙二醇中与 NH3·H2O 环合，得到 5-氟吡唑[3,4-b]吡啶-3-胺（9）。将中间体（9）与异戊醇亚硝酸盐和 BF3·Et2O 在 THF 中偶联，然后使用 NaI 在丙酮中进行碘化，得到 5-氟-3-碘吡唑[3,4-b]吡啶（10），接着在 Cs2CO3 存在下与 2-氟苯基溴化物（11）进行 N-烷基化，得到 5-氟-1-(2-氟苯基)-3-碘吡唑[3,4-b]吡啶（12）。中间体（12）与 Bu3Sn 反应后，在回流二氧六环中与 2-氯-5-硝基嘧啶-4,6-二胺（13）在 Pd(PPh3)4 存在下进行 Stille 偶联，得到中间体（14）。 """ 使用 H 2 在 Pd/C 上对中间体（14）进行硝基还原，在吡啶中生成三氨基嘧啶衍生物（15），最后在吡啶/CH 2 Cl 2 中与甲基氯甲酸酯（16）缩合，得到 vericiguat[81]，[82]。中间体（13）的合成涉及首先用 HNO 3 对 6-氨基尿嘧啶（17）进行硝化，生成 6-氨基-5-硝基尿嘧啶（18），然后与 POCl 3 和 PhNMe 2 进行氯化，得到 2,6-二氯-5-硝基嘧啶-4-胺（19）。将中间体（14）与乙醇 NH 3 在醚中进行胺化，得到 2-氯-5-硝基嘧啶-4,6-二胺（13）[83]。 """
The sulfonylation of 2,2,3,3-tetrafluoropropan-1-ol (20) with Tf2O at 70 °C gives the corresponding sulfonate (21), which is then condensed with morpholine (22) in CH2Cl2 to yield 4-(2,2,3,3-tetrafluoropropyl) morpholine (23) (2,3) [80]. This compound can be alternatively obtained by the coupling of 2,2,3,3-tetrafluoropropyltosylate (24) with morpholine (22) at 130 °C (7). N-Alkylation of intermediate (23) with methyl mesylate (25) at 135 °C provides 4-methyl-4-(2,2,3,3-tetrafluoropropyl) morpholin-4-ium mesylate (26), which is dehydrogenated with NaOH in H2O to provide 4-methyl-4-[2,3,3-trifluoro-1(E)-propenyl] morpholin-4-ium mesylate (27) [80], [84]. The demethylation of intermediate (27) using morpholine and Et3N in H2O/CH2Cl2 at 75 °C leads to 2(E)-fluoro-3-(4-morpholinyl) acrylaldehyde (28). The cyclization of this compound (28) with ethyl 5-amino-1-(2-fluorobenzyl) pyrazole-3-carboxylate (31) (prepared by the cyclization of ethyl cyanopyruvate sodium salt (29) with (2-fluorobenzyl) hydrazine (30) using trifluoroacetic acid (TFA) in refluxing dioxane) in the presence of MsOH and LiCl or HCl in refluxing EtOH affords a pyrazolo[3,4-b] pyridine derivative (32) [85], [86]. The reaction of ester (32) with HCONH2 and NaOMe in MeOH yields carboxamide (33), which is dehydrated with POCl3 in sulfolane/acetonitrile to furnish intermediate (34) (2,3). Compound 36 can also be prepared by the substitution of 5-fluoro-1-(2-fluorobenzyl)-3-iodopyrazolo[3,4-b] pyridine (12) with CuCN in DMSO at 150 °C. 5-Fluoro-1-(2-fluorobenzyl) pyrazolo[3,4-b] pyridine-3-carbonitrile (34), upon reaction with NaOMe in MeOH and subsequent treatment with NH4Cl, optionally in the presence of AcOH, yields 5-fluoro-1-(2-fluorobenzyl) pyrazolo[3,4-b] pyridine-3-carboximidamide acetate (35a) or hydrochloride salt (35b). The cyclization of intermediates (35a) or (35b) with [(E)-phenyldiazenyl] malononitrile (38) (obtained by the diazotization of aniline (36) with NaNO2 and HCl in H2O, followed by condensation with malononitrile (37) using NaOAc in H2O/EtOH) in the presence of Et3N at high temperature (100 °C) produces the diazo compound (39). The reduction of intermediate (39) using H2 over Pd/C in DMF affords the triaminopyrimidine intermediate (15), which is ultimately condensed with methyl chloroformate (16) in pyridine/CH2Cl2 to yield the target compound.
2,2,3,3-四氟丙醇（20）在 70°C 下与三氟甲磺酸酐（Tf2O）进行磺化反应，得到相应的磺酸盐（21），然后与吗啡啉（22）在 CHCl2 中缩合，得到 4-(2,2,3,3-四氟丙基)吗啡啉（23）（2,3）[80]。该化合物还可以通过 2,2,3,3-四氟丙基甲磺酰基（24）与吗啡啉（22）在 130°C 下的偶联反应获得（7）。将中间体（23）用甲基甲磺酸酯（25）在 135°C 下进行 N-烷基化，得到 4-甲基-4-(2,2,3,3-四氟丙基)吗啡啉-4-ium 甲磺酸盐（26），然后用 NaOH 在 H2O 中脱氢，得到 4-甲基-4-[2,3,3-三氟-1(E)-丙烯基]吗啡啉-4-ium 甲磺酸盐（27）[80]，[84]。使用吗啡啉和 Et3N 在 H2O/CHCl2 中于 75°C 下对中间体（27）进行去甲基化，得到 2(E)-氟-3-(4-吗啡啉基)丙烯醛（28）。 该化合物（28）与乙基 5-氨基-1-（2-氟苯基）吡唑-3-羧酸酯（31）（通过乙基氰丙酸钠盐（29）与（2-氟苯基）肼（30）在回流二氧六环中，使用三氟乙酸（TFA）进行环合制备）在 MsOH 和 LiCl 或 HCl 在回流乙醇中的存在下环合，得到吡唑并[3,4-b]吡啶衍生物（32）[85]，[86]。酯（32）与 HCONH 2 和 NaOMe 在甲醇中的反应生成羧酰胺（33），然后与 POCl 3 在亚磺酰烷/乙腈中脱水，得到中间体（34）（2,3）。化合物 36 也可以通过在 DMSO 中，于 150°C 下用 CuCN 对 5-氟-1-（2-氟苯基）-3-碘吡唑并[3,4-b]吡啶（12）进行取代来制备。5-氟-1-（2-氟苯基）吡唑并[3,4-b]吡啶-3-腈（34），与 NaOMe 在甲醇中反应，随后用 NH 4 Cl 处理，可选地在醋酸的存在下，得到 5-氟-1-（2-氟苯基）吡唑并[3,4-b]吡啶-3-羧基脒乙酸盐（35a）或盐酸盐（35b）。 中间体（35a）或（35b）与[(E)-苯偶氮基]丙二晴（38）（通过在 H2O 中用 NaNO2 和 HCl 对苯胺（36）进行重氮化，然后使用 NaOAc 在 H2O/乙醇中与丙二晴（37）进行缩合得到）在 Et3N 存在下，在高温（100°C）下环化，生成偶氮化合物（39）。使用 H2 在 Pd/C 上还原中间体（39），在 DMF 中得到三氨基嘧啶中间体（15），最终在吡啶/CHCl3 中与甲酰氯（16）缩合，得到目标化合物。
In general, there are fewer reaction steps in route 1 than in route 2, which can undoubtedly reduce the cost of reagents, and the reaction conditions are safe and easy to achieve. However, due to the low yields of compounds 13 to 15 in both steps, the route's yield is also limited. Nevertheless, there is still no report on the optimization of processes. In comparison, although route 2 is longer, the conversion rate of each step is high, and the total yield is nearly 10 times higher than that of route 1. The safety of the process from compound 37 to vericiguat has already been proven in the synthesis of riociguat. This part of route 2 can be applied to production on the 100 kg scale [87]. Therefore, this route is also mainstream in actual production applications [88], [89]. However, route 2 also uses POCl3 in the dehydration reaction of compounds 33 to 34 at 170 °C, which are relatively harsh reaction conditions. Recently, it was discovered that the reaction can also be catalysed by silane using PhSiH3 by using a catalytic amount of fluoride, which is milder and more selective [90], [91], [92].
总的来说，路线 1 的反应步骤比路线 2 少，这无疑可以降低试剂的成本，并且反应条件安全且易于实现。然而，由于化合物 13 至 15 在两个步骤中的产率都较低，该路线的产率也受到限制。尽管如此，关于工艺优化的报道仍然没有。相比之下，虽然路线 2 的步骤更长，但每个步骤的转化率都很高，总产率几乎是路线 1 的 10 倍。从化合物 37 到瑞戈非特的合成过程的安全性已经在瑞戈非特的合成中得到证实。路线 2 的这一部分可以应用于 100 公斤规模的量产[87]。因此，该路线在实际生产应用中也是主流[88][89]。然而，路线 2 在化合物 33 至 34 的脱水反应中也使用了 POCl 3 ，在 170°C 的条件下，这些条件相对苛刻。最近发现，通过使用 PhSiH 3 和氟化物作为催化剂，反应也可以由硅烷催化，这种方法更加温和且更具选择性[90][91][92]。

4. Preclinical studies and clinical trials
4. 预临床研究和临床试验

4.1. Preclinical studies 4.1 预临床研究

There are relatively few preclinical studies of vericiguat. As an sGC stimulator, vericiguat was shown to stimulate high-purity recombinant sGC in a dose-dependent manner from 0.01 to 100 µM. When used (100 µM) in combination with the NO/NO donor diethylamide complex (100 nM), vericiguat synergistically enhanced sGC activity. In the presence of the sGC inhibitor 1H-[1], [2], [4]oxadiazolo[4,3-a]quinoxolin-1-one, the efficacy of vericiguat was almost completely blocked. Vericiguat showed effective selectivity for sGC and acted synergistically with NO. At the same time, Markus Follmann et al. confirmed in rats that vericiguat has good therapeutic potential for cardiorenal syndrome-related cardiovascular diseases [93], [94], [95].
关于 vericiguat 的预临床研究相对较少。作为一种 sGC 激动剂，vericiguat 在 0.01 至 100 µM 的剂量范围内以剂量依赖性方式刺激高纯度重组 sGC。当与 NO/NO 供体二乙胺复合物（100 nM）联合使用时，vericiguat 协同增强了 sGC 活性。在 sGC 抑制剂 1H-[1]，[2]，[4]氧代杂氮唑[4,3-a]喹啉-1-酮的存在下，vericiguat 的疗效几乎完全被阻断。vericiguat 对 sGC 表现出有效的选择性，并与 NO 协同作用。同时，Markus Follmann 等人通过大鼠实验证实，vericiguat 在治疗与心肾综合征相关的 cardiovascular diseases 方面具有良好的治疗潜力[93]，[94]，[95]。

4.2. Clinical trials 4.2. 临床试验

Vericiguat was developed by Bayer almost a decade ago and is still being tested in clinical trials. A total of 10 clinical trials were disclosed and completed. As shown in Table 1 and Fig. 12, the main indications are HF and CAD.
维瑞吉尤特是由拜耳公司近十年前开发的，目前仍在临床试验中进行测试。共披露并完成了 10 项临床试验。如表 1 和图 12 所示，主要适应症为心力衰竭和冠心病。

Table 1. Clinical trials of vericiguat.
表 1. vericiguat 的临床试验。

No. 不。NCT number NCT 编号Title acronym 标题缩写Study title 研究标题Phase 阶段ConditionNumber enrolledStatus
1NCT04722484/A Trial to Learn How Safe Vericiguat (BAY1021189) is and the Way the Body Absorbs, Distributes and Gets Rid of Vericiguat in Participants with Kidney Disease and in Age-, Weight- and Gender-matched Healthy Participants
一项关于评估贝利吉尤（BAY1021189）的安全性及其在患有肾脏疾病的患者和年龄、体重和性别匹配的健康参与者中的吸收、分布和排泄方式的临床试验		ⅠHF39Completed
2NCT04722562/A Trial to Learn How Safe Vericiguat (BAY1021189) is and the Way the Body Absorbs, Distributes and Gets Rid of Vericiguat in Participants with Liver Disease and in Age-, Weight- and Gender-matched Healthy Participants
一项关于评估肝病患者及年龄、体重和性别匹配的健康受试者中 Vericiguat（BAY1021189）的安全性及其在体内吸收、分布和排泄方式的临床试验		ⅠHF27Completed
3NCT03547583VITALITY-HFpEF 活力-HFpEFPatient-reported Outcomes in Vericiguat-treated Patients with Heart failure with preserved ejection fraction (HFpEF)
患者报告结局在射血分数保留型心力衰竭（HFpEF）接受维利吉单抗治疗的患者中		ⅡHFpEF789Completed
4NCT03504982/Study to Evaluate the QT/QTc Interval Prolongation Potential of Vericiguat
研究评估维利吉脲对 QT/QTc 间期延长潜力的研究		ⅠCAD74Completed
5NCT03255512VISORVericiguat Drug–drug Interaction Study with Isosorbite Mononitrate in Stable Coronary Artery Disease Patients
维西吉他药物与异山梨酯单硝酸酯在稳定型冠状动脉疾病患者中的药物相互作用研究		ⅠCAD41Completed
6NCT03145038/Relative Bioavailability and Food Effect Study with Vericiguat to Characterize the Paediatric Formulation in Adult Healthy Subjects
相对生物利用度和食物效应研究——以维立古单用于儿童配方在成年健康受试者中的特征化		ⅠPharmacokinetics30Completed
7NCT02861534VICTORIAA Study of Vericiguat in Participants with Heart Failure with Reduced Ejection Fraction (HFrEF) (MK-1242–001)
《关于射血分数降低的心力衰竭患者中应用维利吉脲的研究（MK-1242–001）》		ⅢHFrEF5050Completed
8NCT02617550VENICEVericiguat Drug–drug Interaction with Nitroglycerin in Stable Coronary Artery Disease Patients
维立吉单抗与硝酸甘油在稳定型冠状动脉疾病患者中的药物相互作用		ⅠCAD36Completed
9NCT01951625/Phase IIb Safety and Efficacy Study of Four Dose Regimens of BAY1021189 in Patients with Heart Failure with Reduced Ejection Fraction Suffering from Worsening Chronic Heart Failure (SOCRATES-REDUCED)
BAY1021189 四种剂量方案在慢性心力衰竭恶化患者中降低射血分数心力衰竭的 IIb 期安全性和有效性研究（SOCRATES-REDUCED）		ⅡHF456Completed
10NCT01951638/Phase IIb Safety and Efficacy Study of Four Dose Regimens of BAY1021189 in Patients with Heart Failure and Preserved Ejection Fraction Suffering from Worsening Chronic Heart Failure (SOCRATES-PRESERVED)
BAY1021189 四种剂量方案在射血分数保留的心力衰竭患者中治疗慢性心力衰竭恶化（SO-CRATES-PRESERVED）的 IIb 期安全性及有效性研究		ⅡHF477Completed
11NCT05093933VICTORA Study of Vericiguat (MK-1242) in Participants With Chronic Heart Failure With Reduced Ejection Fraction (HFrEF) (MK-1242–035) (VICTOR)
《关于慢性心力衰竭（射血分数降低）患者使用维利吉特（MK-1242）（MK-1242–035）的研究（VICTOR）》		ⅢHFrEF6000Recruiting
12NCT05086952/A Study in Healthy Adult Male Participants to Learn the Way Vericiguat is Absorbed With and Without Food When Taken as a Single Dose in Liquid Form Suitable for Children Compared to a 10 Milligram (mg) Tablet That Releases the Active Substance Immediately
一项关于健康成年男性受试者的研究，旨在了解儿童专用液体剂型维利吉脲在空腹和餐后单剂量给药时与 10 毫克（mg）立即释放活性成分的片剂相比的吸收方式		ⅠHFC36Recruiting
Fig. 12
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Fig. 12. The clinical trial timeline of vericiguat.
图 12. vericiguat 的临床试验时间线。

Fig. 13
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Fig. 13. Vericiguat metabolites in human hepatocytes.
图 13. 人肝细胞中的维利西瓜酸代谢物。

4.2.1. HF . 4.2.1. HF

There have been 3 phase I clinical trials of vericiguat in the context of HF. HF patients have many complications, and kidney and liver diseases are very common. To evaluate the expected use of vericiguat in these patients, two related clinical trials (NCT04722484 and NCT04722562) were carried out. Through the use of participants with varying degrees of liver and kidney disease, it was concluded that discretionary adjustment of the drug dosage is not recommended for these patients [23]. In addition, a study on the relative bioavailability and effect of food on the drug (NCT03145038) showed that vericiguat is suitable for postprandial administration and could be taken concomitantly with gastric acid-modifying drugs [96], [97].
在心力衰竭（HF）的背景下，vericiguat 已经进行了 3 项 I 期临床试验。心力衰竭患者并发症众多，肾脏和肝脏疾病尤为常见。为了评估 vericiguat 在这些患者中的预期应用，开展了两项相关临床试验（NCT04722484 和 NCT04722562）。通过使用不同程度的肝肾功能受损的参与者，得出结论：不建议对这些患者进行药物剂量的随意调整[23]。此外，关于食物对药物相对生物利用度和影响的研究（NCT03145038）表明，vericiguat 适合餐后服用，并且可以与胃酸调节药物同时使用[96]，[97]。
Since 2013, three phase II clinical trials on the safety and tolerability of vericiguat have been carried out. The results showed that vericiguat doses of 2.5–5 mg/10 mg improved quality of life for and were well tolerated by both HFrEF and HFpEF patients (SOCRATES-REDUCED and SOCRATES-PRESERVED) [98], [99], [100]. However, even if the dosage was increased to 15 mg/d, vericiguat showed little benefit for improving exercise tolerance (SOCRATES-PRESERVED) [101], [102].
自 2013 年以来，已经进行了三项关于 vericiguat 安全性和耐受性的 II 期临床试验。结果显示，2.5-5 mg/10 mg 的 vericiguat 剂量能够改善 HFrEF 和 HFpEF 患者的生存质量，并且这两种患者都能很好地耐受这种剂量（SOCRATES-REDUCED 和 SOCRATES-PRESERVED）[98]、[99]、[100]。然而，即使剂量增加到每天 15 mg，vericiguat 在改善运动耐受性方面也显示出很少的益处（SOCRATES-PRESERVED）[101]、[102]。
As an important phase III clinical trial, VICTORIA (NCT02861534) has achieved great success [103]. The VICTORIA trial demonstrated the effectiveness of vericiguat in 5050 patients with worsening HFrEF[104]. Vericiguat significantly reduced the incidence of the primary outcome of death from cardiovascular causes or first hospitalization for HF among the patients [105], [106]. Benefiting from the success of the VICTORIA trial, two new trials in HF were launched. VICTOR, a phase III trial, intends to expand the applicable population of vericiguat and recruit patients with general HFrEF. NCT05086952 is a phase I trial of a new liquid formulation of vericiguat.
作为一项重要的 III 期临床试验，VICTORIA（NCT02861534）取得了巨大成功[103]。VICTORIA 试验证实了 vericiguat 在 5050 名心功能不全（HFrEF）恶化患者中的有效性[104]。vericiguat 显著降低了患者因心血管原因死亡或首次因心衰住院的发病率[105]，[106]。得益于 VICTORIA 试验的成功，启动了两个新的心衰试验。VICTOR 是一项 III 期试验，旨在扩大 vericiguat 的适用人群，并招募一般 HFrEF 患者。NCT05086952 是一项 vericiguat 新液体制剂的 I 期临床试验。

4.2.2. Coronary artery disease (CAD)
4.2.2. 冠状动脉疾病（CAD）

Bayer and Merck are also carrying out clinical trials on vericiguat for CAD. VISOR and VENICE explored the possibility of vericiguat with short- or long-acting nitrates in patients with stable CAD, and the combination was well tolerated [107]. However, in NCT03504982, the potential of vericiguat to prolong the QT/QTc interval and adjust heart rate in patients with CAD was not obvious [23].
拜耳公司和默克公司也在对 vericiguat 进行 CAD 的临床试验。VISOR 和 VENICE 研究了 vericiguat 与短效或长效硝酸盐在稳定型 CAD 患者中的可能性，该组合耐受性良好[107]。然而，在 NCT03504982 研究中，vericiguat 在延长 CAD 患者 QT/QTc 间期和调整心率方面的潜力并不明显[23]。

5. ADMET and drug interactions
5. 药物 ADMET 特性和药物相互作用

5.1. ADME 5.1. 药代动力学/药效学

The results of the absorption, distribution, metabolism and excretion (ADME) study of vericiguat in humans are clear and complete. Like most small-molecule drugs, vericiguat is administered orally, which means that it enters the blood and binds to plasma proteins after gastrointestinal absorption. Because the compound contains many N atoms, its pKa reaches 4.7, which is weakly basic [108]. Therefore, it is basically nonionic in the pH range of the gastrointestinal tract, and the absorption is fast and complete, so the drug effect is rapidly exerted. The specific parameters were a steady-state average (coefficient of variation %) Cmax of vericiguat in patients of 350 mcg/L (29%) and an AUC of 6680 mcg/h/L (33.9%) following administration of 10 mg vericiguat. In addition, the percentage accumulation of vericiguat in plasma was as high as 155–171% and reached a stable state after 6 days. In healthy subjects, the steady-state distribution volume of vericiguat was approximately 44 L, and the protein binding rate reached 98% [108].
人体中 vericiguat 的吸收、分布、代谢和排泄（ADME）研究结果清晰完整。与大多数小分子药物一样，vericiguat 通过口服给药，这意味着它在胃肠道吸收后进入血液并绑定到血浆蛋白。由于该化合物含有许多 N 原子，其 pKa 值为 4.7，呈弱碱性[108]。因此，在胃肠道 pH 范围内，它基本上是非离子的，吸收快速且完全，因此药物作用迅速发挥。具体参数为 vericiguat 在患者体内的稳态平均浓度（变异系数%）为 350 mcg/L（29%），在给予 10 mg vericiguat 后，其 AUC 为 6680 mcg/h/L（33.9%）。此外，vericiguat 在血浆中的累积百分比高达 155-171%，并在 6 天后达到稳态。在健康受试者中，vericiguat 的稳态分布体积约为 44 L，蛋白结合率达到了 98%[108]。
Riociguat is mainly metabolized in phase I, and the main metabolite is demethylated nelociguat [109], [110]. While the methyl substitution of the carbamate moiety in the tail is removed in vericiguat, the metabolic pathway is shifted to phase II glucuronidation (95%), which prolongs the metabolic time. The main metabolite of vericiguat is compound 40, which is obtained by the transfer of the glucuronic acid group of uridine diphosphate glucuronic acid (UDPGA) to the amino group of the pyrimidine ring [111]. This conversion increases water solubility, making it easier to excrete vericiguat in liquid form, which explains why the metabolites of vericiguat are mainly excreted in urine (53%) [112], [113]. Two enzymes, UGT1A9 and UGT1A1, play the role of glucuronidation, and the first is the main enzyme. Since vericiguat is basically ineffective against the CYP enzyme system (50% inhibitory concentration (IC50) > 50 μM) (Table 2), phase Ⅰ is metabolized very little, accounting for only 5% of all metabolites, and compound 41 is a rare metabolite of this type Fig. 13 [108]. In addition, compared with riociguat, vericiguat has an F atom on the central skeleton, which also played a role in delaying metabolism [114], [115].
Riociguat 主要在 I 相代谢，其主要代谢产物是去甲基化后的 nelociguat [109]，[110]。虽然 vericiguat 的尾部羧基甲基取代基被去除，但其代谢途径转变为 II 相的葡萄糖醛酸化（95%），这延长了代谢时间。vericiguat 的主要代谢产物是化合物 40，它通过将尿苷二磷酸葡萄糖醛酸（UDPGA）的葡萄糖醛酸基团转移到嘧啶环的氨基上得到 [111]。这种转化增加了水溶性，使得 vericiguat 更容易以液体形式排出，这也解释了为什么 vericiguat 的代谢产物主要通过尿液排出（53%）[112]，[113]。两种酶 UGT1A9 和 UGT1A1 在葡萄糖醛酸化中发挥作用，其中 UGT1A9 是主要酶。由于 vericiguat 对 CYP 酶系统的抑制作用基本无效（50%抑制浓度（IC50）> 50 μM）（见表 2），I 相代谢非常少，仅占所有代谢产物的 5%，化合物 41 是这类代谢产物中较为罕见的代谢物（图 13 [108]）。 此外，与里奥西古特相比，维里西古特在中央骨架上有一个 F 原子，这也起到了延缓代谢的作用[114]，[115]。

Table 2. Inhibitory effect of vericiguat on the CYP enzyme system.
表 2. 维立西格对 CYP 酶系抑制效应。

CYP isoform CYP 亚型System 系统Material 材料Substrate 基材Parameter
CYP1A2in vitro 体外Liver (microsomes), human
肝（微粒体），人		Phenacetin 非那西汀IC50 > 50 μM
CYP2A6Coumarin 香豆素
CYP2B6Bupropion 布普瑞酮
CYP2C19S-Mephenytoin S-苯妥英
CYP2C8Amodiaquine 阿莫地喹
CYP2C9Diclofenac 迪克洛芬酸
CYP2D6Dextromethorphan 右美沙芬
CYP2E1Chlorzoxazone 氯唑沙宗
CYP3A4Midazolam 咪达唑仑
CYP3A4Testosterone 睾酮

5.2. Toxicity 5.2. 毒性

Based on previous animal models and clinical studies, vericiguat is not indicated for use in all populations. In animal reproduction studies, oral administration of 4–24 times the human dose (maximum 10 mg) of vericiguat to pregnant rabbits could cause heart and major vascular malformations, increase the occurrence of miscarriage, reduce the weight of the pups, and increase pup mortality. Another toxicity study found that vericiguat was present in the milk of lactating rats, and the drug or its metabolites were thus considered likely to be present in human breast milk. Therefore, vericiguat is not recommended for use by pregnant patients, and breastfeeding is not recommended for women taking the drug
基于先前动物模型和临床研究，维立西格他并不适用于所有人群。在动物繁殖研究中，给怀孕家兔口服维立西格他的人体剂量 4-24 倍（最大 10 毫克）可能导致心脏和主要血管畸形，增加流产发生率，降低幼崽体重，并增加幼崽死亡率。另一项毒性研究表明，维立西格他存在于哺乳大鼠的乳汁中，因此该药物或其代谢物很可能存在于人乳中。因此，不建议孕妇使用维立西格他，且不建议哺乳期妇女服用该药物。[23]. Such female patients should inform their doctor of all health conditions. In a toxicology study of growing rats, vericiguat exerted reversible effects on bone formation, including growth plate hypertrophy and bone hyperplasia, and induced remodelling of the metaphysis and diaphysis. Therefore, vericiguat is also not indicated for use in toddlers, children, or adolescents. In addition, 1596 (63%) patients 65 years and older who received vericiguat treatment in the VICTORIA study were assessed. There was no overall difference in the safety or effectiveness of the drug between older patients and younger patients, but it cannot be ruled out that some older people may be more sensitive to the drug.
. 这类女性患者应向医生告知所有健康状况。在一项关于成长大鼠的毒理学研究中，维立西格特对骨骼形成产生了可逆的影响，包括生长板肥大和骨增生，并诱导了干骺端和骨干的重建。因此，维立西格特也不适用于幼儿、儿童或青少年使用。此外，在 VICTORIA 研究中，有 1596 名（63%）65 岁及以上的患者接受了维立西格特治疗，对其进行了评估。老年患者与年轻患者在药物的安全性或有效性方面没有总体差异，但不能排除一些老年人可能对药物更为敏感。

5.3. Drug interactions 5.3. 药物相互作用

In addition to showing good tolerance when used with short- and long-acting nitrates in the VENICE and VISOR trials, vericiguat administered in combination with other drugs has been investigated in a number of studies.
除了在 VENICE 和 VISOR 试验中使用短效和长效硝酸盐时表现出良好的耐受性外，vericiguat 与其他药物联合使用的情况已在多项研究中进行了调查。
A phase I clinical trial conducted in healthy volunteers investigated the effects of vericiguat on the pharmacodynamics and pharmacokinetics of other commonly used drugs (warfarin, ARNI, aspirin) in HF populations. Compared to aspirin alone (1000 mg), the joint use of these drugs with 15 mg q.d. vericiguat had no impact on platelet aggregation or bleeding time; the least squares estimated differences were 2.7% and 2.4%, respectively. Vericiguat 10 mg q.d. had no significant effect on the coagulation inhibitory effect of warfarin (25 mg). Compared with placebo, the combination of single/multidose vericiguat (2.5 mg) and an ARNI (97/103 mg) showed no related pharmacokinetic changes in volunteers (difference in systolic BP: −1.66 mmHg [90% CI - 4.22 to 0.90]; difference in diastolic BP: −1.80 mmHg [90% CI - 3.24 to - 0.36]; difference in heart rate: −0.33 beats/min [90% CI - 2.25 to 1.60]). Moreover, combinations of ketoconazole, mefenamic acid, digoxin, or rifampicin with vericiguat were administered to healthy subjects. The results showed that there was no significant clinical difference in the pharmacokinetics of vericiguat when used in combination with any of these drugs [116]. Therefore, the simultaneous use of the abovementioned drugs and vericiguat is supported.
一项在健康志愿者中进行的 I 期临床试验，研究了 vericiguat 对心力衰竭（HF）人群中常用药物（华法林、ARNI、阿司匹林）的药代动力学和药效学的影响。与单独使用阿司匹林（1000 毫克）相比，这些药物与每日一次 15 毫克的 vericiguat 联合使用，对血小板聚集或出血时间没有影响；最小二乘法估计的差异分别为 2.7%和 2.4%。每日一次 10 毫克的 vericiguat 对华法林（25 毫克）的凝血抑制作用没有显著影响。与安慰剂相比，单剂量或多剂量 vericiguat（2.5 毫克）与 ARNI（97/103 毫克）联合使用，在志愿者中没有相关的药代动力学变化（收缩压差异：-1.66 毫米汞柱[90%置信区间-4.22 至 0.90]；舒张压差异：-1.80 毫米汞柱[90%置信区间-3.24 至-0.36]；心率差异：-0.33 次/分钟[90%置信区间-2.25 至 1.60]）。此外，将酮康唑、美洛昔康、地高辛或利福平与 vericiguat 联合给药给健康受试者。结果显示，vericiguat 与这些药物中的任何一种联合使用时，其药代动力学没有显著的临床差异[116]。 因此，同时使用上述药物与维利吉尤特是支持的。
According to “FDA Approved Drug Products: Verquvo (vericiguat) oral tablets”, when vericiguat (10 mg) was used in combination with sildenafil (25, 50, or 100 mg), BP in a seated position decreased by 5.4 mmHg (systolic/diastolic BP, mean arterial pressure). The use of PDE5 inhibitors in combination with vericiguat was not recommended. In addition, the concurrent use of vericiguat and other sGC stimulators was prohibited.
根据“美国食品药品监督管理局批准的药物产品：Verquvo（vericiguat）口服片”，当 vericiguat（10 毫克）与西地那非（25、50 或 100 毫克）联合使用时，坐位血压（收缩压/舒张压，平均动脉压）降低 5.4 毫米汞柱。不建议将 PDE5 抑制剂与 vericiguat 联合使用。此外，禁止同时使用 vericiguat 和其他 sGC 激动剂。

6. Summary and future perspectives
6. 摘要及未来展望

HFrEF is an important public health issue, and research on the mechanism, pathophysiology and prevention of HFrEF has achieved remarkable results in the past 40 years. However, the morbidity and mortality rates of patients after hospitalization remain very high [117]. The sGC stimulator vericiguat bypasses the traditional pathway and affects the NO-sGC-cGMP pathway [118]. This new mechanism of action provides new options for patients and reduces the risk of deterioration. At the same time, vericiguat avoids many issues, such as drug dose-dependent tolerance, a gradual decline in effectiveness, and off-target effects due to a lack of specificity. However, the structural optimization of vericiguat, the specific docking with sGC, and how cGMP can improve HF by regulating downstream pathways still require in-depth research.
HFrEF（射血分数降低的心力衰竭）是一个重要的公共卫生问题，过去 40 年来，对其机制、病理生理学和预防的研究取得了显著成果。然而，住院后患者的发病率和死亡率仍然非常高[117]。sGC 激动剂维利吉乌特绕过传统途径，影响 NO-sGC-cGMP 途径[118]。这种新的作用机制为患者提供了新的选择，并降低了病情恶化的风险。同时，维利吉乌特避免了许多问题，如药物剂量依赖性耐受性、疗效逐渐下降以及由于缺乏特异性而产生的脱靶效应。然而，维利吉乌特的构效优化、与 sGC 的特异性结合以及 cGMP 通过调节下游途径改善心衰的机制仍需深入研究。
Based on the successful VICTORIA trial, vericiguat was approved for launch. In the VICTORIA study, vericiguat significantly reduced the incidences of hospitalization and cardiovascular death due to HF compared with GDMT. In addition, vericiguat exhibits significant advantages because it does not increase electrolyte imbalance or renal damage [119]. However, vericiguat users have symptomatic hypotension, which requires further clinical studies to assess patient tolerance [120]. The VICTORIA trial had other limitations. For example, the proportion of male patients was 75%, and the proportion of black patients was only 5%. In addition, since fewer patients were treated with SGLT2 inhibitors and ARNIs, it remains to be determined whether these drugs have a potential potentiation effect in patients with HFrEF. At the same time, SGLT2 inhibitors and ARNIs are currently the only drugs that can be used to treat HFpEF. Given that there are fewer drug options, whether vericiguat has a synergistic effect on patients with HFpEF urgently needs to be confirmed. Last but not least, there are still few studies on the combination of vericiguat with other drugs and the resulting potential complications [42]. All of the above tests still need to be carried out. We expect that vericiguat will have the same therapeutic effect on children and adults with chronic HFrEF that has not worsened.
基于成功的 VICTORIA 试验，vericiguat 获得了上市批准。在 VICTORIA 研究中，vericiguat 与 GDMT 相比，显著降低了 HF 导致的住院和心血管死亡发生率。此外，vericiguat 还具有显著优势，因为它不会增加电解质失衡或肾脏损伤[119]。然而，vericiguat 使用者会出现症状性低血压，需要进一步的临床研究来评估患者的耐受性[120]。VICTORIA 试验还存在其他局限性。例如，男性患者的比例占 75%，黑人患者的比例仅为 5%。此外，由于接受 SGLT2 抑制剂和 ARNI 治疗的患者较少，尚需确定这些药物在 HFrEF 患者中是否具有潜在的协同作用。同时，SGLT2 抑制剂和 ARNI 是目前唯一可用于治疗 HFpEF 的药物。鉴于药物选择较少，vericiguat 在 HFpEF 患者中的协同作用迫切需要得到证实。 最后但同样重要的是，关于维立西格与其它药物联合使用及其潜在并发症的研究仍然很少[42]。上述所有测试仍需进行。我们预计，维立西格对慢性 HFrEF 儿童和成人患者都将产生相同的治疗效果，前提是病情没有恶化。
In the current situation of individualized treatment of patients, an ageing population and limited resources, how, where and when to manage the growing public health problem of HF is a great challenge. Drug therapy is the main treatment method for all patients with HF, but patients should also devote attention and effort to lifestyle changes, actively avoid poor lifestyle habits, and undergo surgical interventions or device implantations when needed [121]. Last but not least, we should also consider whether the current practice of blindly adding drugs to GDMT is appropriate: the answer is almost certainly no, as this may eventually become unbearable to patients. Therefore, verifying the effect of a single drug, determining its optimal dose and tolerability, and selecting a truly powerful drug combination for patient treatment should become important issues that we consider in the development of new drugs.
在当前患者个体化治疗、人口老龄化和资源有限的情况下，如何、在哪里以及何时管理不断增长的心力衰竭（HF）这一公共卫生问题，是一个巨大的挑战。药物治疗是所有心力衰竭患者的首选治疗方法，但患者也应关注并努力改变生活方式，积极避免不良生活习惯，并在必要时进行手术干预或植入设备[121]。最后但同样重要的是，我们也应考虑目前盲目添加药物到常规治疗方案（GDMT）的做法是否合适：答案几乎肯定是不，因为这最终可能会让患者难以承受。因此，验证单一药物的效果、确定其最佳剂量和耐受性，以及为患者选择真正有效的药物组合，应成为我们在新药研发中考虑的重要问题。

Funding 资助

This work was supported by the National Natural Science Foundation of China (Nos. 81602967, 82003699 and 81803784), the Basic Research Program of Natural Science of Shaanxi Province (Nos. 2020CGXNG-044, 2019JQ-252, 2019JQ-779 and 2019JQ-484), the Basic Research Plan of the Education Department of Shaanxi Province (No. 19JC006), the Research Fund of Guangdong Medical University (GDMUM201940), the China Postdoctoral Science Foundation (Nos. 2016M592898XB and 2019M663921XB), the Natural Science Foundation of Shandong Province (No. ZR2020MH141), the Shandong Post-Doctoral Innovation Project (No. 202003063), and the Medical and Health Science and Technology Development Program of Shandong Provinc (No. 202003070813).
这项工作得到了国家自然科学基金委员会（项目编号：81602967、82003699 和 81803784）的支持，陕西省自然科学基础研究计划（项目编号：2020CGXNG-044、2019JQ-252、2019JQ-779 和 2019JQ-484），陕西省教育厅基础研究计划（项目编号：19JC006），广东医科大学研究基金（GDMUM201940），中国博士后科学基金（项目编号：2016M592898XB 和 2019M663921XB），山东省自然科学基金（项目编号：ZR2020MH141），山东省博士后创新项目（项目编号：202003063），以及山东省医疗卫生科技发展计划（项目编号：202003070813）。

CRediT authorship contribution statement
CRediT 作者贡献声明

J.X., N.H. and C.Y.L.: Conceptualization. J.X., N.H.: Writing – original draft. K.W. and C.Y.L.: Writing – review & editing. L.T., J.Z., J.F.L., J.W., X.D.R.: Visualization. J.X., X.L.X: Revising.
J.X., N.H. 和 C.Y.L.：构思。J.X. 和 N.H.：撰写——初稿。K.W. 和 C.Y.L.：撰写——审阅与编辑。L.T.，J.Z.，J.F.L.，J.W.，X.D.R.：可视化。J.X.，X.L.X：修订。

Conflict of interest statement
利益冲突声明

The authors declared that they have no conflicts of interest to this work.
作者声明，他们与这项工作无利益冲突。

Acknowledgements 致谢

The English was corrected by American Journal Experts (order No. D7HZKD3P).
英文由美国期刊专家（订单号：D7HZKD3P）进行校对。

Data availability 数据可用性

No data was used for the research described in the article.
未使用任何数据进行研究，如文章所述。

References

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