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

This is VAERS ID 1034182



Case Details

VAERS ID: 1034182 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-01-29
Onset:2021-02-01
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN 5318 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaemia, Atrial fibrillation, Atrial flutter, Cardiac failure congestive, Condition aggravated, Coronary artery disease, Death, Dyslipidaemia, Essential hypertension, Left ventricular failure, Liver function test abnormal, Mitral valve incompetence, Renal failure, Renal tubular necrosis, Thrombocytopenia, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Dyslipidaemia (narrow), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Hypertension (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Lipodystrophy (broad), Renovascular disorders (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Symbicort inhaler 2 puffs BID Cardura 8 mg PO daily Oxygen at night
Current Illness: OSA started on oxygen at night Dysphagia - work up
Preexisting Conditions: Sleep apnea Joint inflammation Hypoxia Past history of MI Hyperlipidemia Back pain Alcohol abuse Hearing loss Nodular hyperplasia of the prostate Asthma TIA Atrial fibrillation, new onset
Allergies: None Known
Diagnostic Lab Data: Primary diagnosis of systolic CHF, mitral valve regurgitation, renal failure with tubular necrosis, abnormal liver function tests, elevated troponin, anemia, thrombocytopenia, atrial fibrillation/flutter, essential hypertension, CAD, dyslipidemia. Work-up with TCU admission. Discharged home on hospice.
CDC Split Type:

Write-up: Approximately 2 weeks post vaccination developed rapid AF, CHF. Admitted to Medical Center. Discharged home on hospice. Patient died at home on 2/13/2021. Reported to this reporter at second dose clinic on 2/16/21. Other details not known. Unknown if related to vaccine.


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