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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1030787



Case Details

VAERS ID: 1030787 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-04
Onset:2021-02-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute myocardial infarction, Atrioventricular block second degree, Bradycardia, Cardiac arrest, Cardiac pacemaker insertion, Chest discomfort, Death, Echocardiogram abnormal, Electrocardiogram ST segment elevation, Nausea, Pulseless electrical activity, Resuscitation, Retching, Unresponsive to stimuli, Ventricular fibrillation, Ventricular hypokinesia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Allopurinol 300mg PO daily, Simvastatin 10mg qhs
Current Illness:
Preexisting Conditions: tubolovillous adenoma, chronic kidney disease, gout, hyperlipidemia, hx of kidney stone.
Allergies: No known drug allergies
Diagnostic Lab Data: EKG (2/12/21) - Sinus rhythm with 2:1 conduction block and anterior ST elevation ECHO bedside (2/12/21) - 1.LVEF< 10% with global diffuse severe hypokinesis - LV stand still.
CDC Split Type:

Write-up: Pt admitted from home with intermittent nausea, dry heaving, and central chest pressure which self resolve in 2 minutes since 2/6/21. Called 911 on 2/12/21 due to sustained episode that did not resolve. EMS treated with aspirin and nitroglycerin prior to arrival to ED. In ED patient became unresponsive and went into full cardiac arrest -CPR and ACLS care initiated. STEMI with AV conduction block. 2nd degree a-v block type II - significant bradycardia - temoprary pacemaker placed - Vfib -PEA. Time of death 0955 on 2/12/21 Patient recieved first dose of Moderna Covid vaccine on 2/4/21


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