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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1168836



Case Details

VAERS ID: 1168836 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-29
Onset:2021-03-06
   Days after vaccination:36
Submitted: 0000-00-00
Entered: 2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Sudden cardiac death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: VITAMINE B COMPLEXE; ALLOPURINOL; CLOPIDOGREL +PHARM; PERINDOPRIL ARGININE; ROSUVASTATINE [ROSUVASTATIN]; METOPROLOL [METOPROLOL TARTRATE]
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: NLMODERNATX, INC.MOD20210

Write-up: Sudden cardiac death; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 23-Mar-2021 and was forwarded to Moderna on 23-Mar-2021. This regulatory authority case was reported by a health care professional (subsequently medically confirmed) and describes the occurrence of SUDDEN CARDIAC DEATH (Sudden cardiac death) in a 58-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 300042722) for COVID-19 vaccination. The patient''s past medical history included No adverse event (No reported medical history). Concomitant products included NICOTINAMIDE, PANTOTHENATE SODIUM, PYRIDOXINE HYDROCHLORIDE, RIBOFLAVIN, VITAMIN B1 NOS (VITAMINE B COMPLEXE), ALLOPURINOL, CLOPIDOGREL BESYLATE (CLOPIDOGREL +PHARM), PERINDOPRIL ARGININE, ROSUVASTATINE [ROSUVASTATIN] and METOPROLOL TARTRATE (METOPROLOL [METOPROLOL TARTRATE]). On 29-Jan-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 26-Feb-2021, received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. The patient died on 06-Mar-2021. The reported cause of death was. It is unknown if an autopsy was performed. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. Treatment information was unknown. Very limited information regarding this event has been provided at this time and additional information is not expected. A causal relationship cannot be excluded Reporter did not allow further contact; Sender''s Comments: Very limited information regarding this event has been provided at this time and additional information is not expected. A causal relationship cannot be excluded; Reported Cause(s) of Death:


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