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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1056336



Case Details

VAERS ID: 1056336 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-19
Onset:2021-01-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ6797 / 1 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Cardiac failure, Condition aggravated, Hypotension
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: Heart failure; Hypotension; Living in nursing home
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: ITPFIZER INC2021193843

Write-up: Worsening of heart failure after vaccination; Worsening of heart failure after vaccination; worsening of hypotension after vaccination; Sudden cardiocirculatory arrest; This is a spontaneous report downloaded from the Medicines Agency (MA) Regulatory Authority-WEB [Ministero Della Salute (MINISAL02)IT-MINISAL02-680104] from a contactable pharmacist. A 92-year-old male patient received the 1st dose of bnt162b2 (COMIRNATY) (lot# EJ6797), intramuscular in left deltoid, on 19Jan2021 at 17:32, at single dose, for COVID-19 immunisation. Medical history included ongoing hypotension, ongoing cardiac failure and ongoing living in residential institution. Concomitant medications were not reported. Clinical picture worsened after vaccination. The patient experienced worsening of heart failure after vaccination on 19Jan2021, worsening of hypotension after vaccination on 19Jan2021, sudden cardiocirculatory arrest on 22Jan2021. The patient was hospitalized in Jan2021 for worsening of heart failure after vaccination and worsening of hypotension after vaccination. The events had fatal outcome on 22Jan2021, as the patient died. An autopsy was not performed.; Reported Cause(s) of Death: Sudden cardiocirculatory arrest; Worsening of hypotension; Worsening of heart failure after vaccination; Worsening of heart failure after vaccination


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