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

This is VAERS ID 1211461



Case Details

VAERS ID: 1211461 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-03-19
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3000496 / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac failure acute
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: DEPAKINE [VALPROATE SODIUM]; MYDOCALM [TOLPERISONE HYDROCHLORIDE]; NOVALGIN [METAMIZOLE SODIUM]; QUETIAPIN ACTAVIS; TEMESTA EXPIDET
Current Illness: Cramps of extremities; Epilepsy; Pain
Preexisting Conditions: Medical History/Concurrent Conditions: Arterial hypertension; Dementia (Neurodegenerative dementia); Glaucoma (bilateral glaucoma); Metastatic breast cancer (status post metastatic breast cancer)
Allergies:
Diagnostic Lab Data:
CDC Split Type: CHMODERNATX, INC.MOD20210

Write-up: Acute heart failure; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 02-Apr-2021 and was forwarded to Moderna on 02-Apr-2021. This regulatory authority case was reported by a physician (subsequently medically confirmed) and describes the occurrence of CARDIAC FAILURE ACUTE (Acute heart failure) in a 74-year-old female patient who received mRNA-1273 (COVID-19 Vaccine Moderna) (batch no. 3000496) for COVID-19 vaccination. The patient''s past medical history included Dementia (Neurodegenerative dementia), Arterial hypertension, Metastatic breast cancer (status post metastatic breast cancer) and Glaucoma (bilateral glaucoma). Concurrent medical conditions included Epilepsy, Cramps of extremities and Pain. Concomitant products included TOLPERISONE HYDROCHLORIDE (MYDOCALM [TOLPERISONE HYDROCHLORIDE]) from 02-Mar-2021 to 21-Mar-2021 for Cramps of extremities, VALPROATE SODIUM (DEPAKINE [VALPROATE SODIUM]) from 18-Feb-2020 to 21-Mar-2021 for Epilepsy, METAMIZOLE SODIUM (NOVALGIN [METAMIZOLE SODIUM]) from 25-Feb-2020 to 21-Mar-2021 for Pain, QUETIAPINE FUMARATE (QUETIAPIN ACTAVIS) from 30-Oct-2020 to 21-Mar-2021 and LORAZEPAM (TEMESTA EXPIDET) from 02-Mar-2021 to 21-Mar-2021 for an unknown indication. On 19-Mar-2021, the patient received dose of mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced CARDIAC FAILURE ACUTE (Acute heart failure) (seriousness criterion death). The patient died on 21-Mar-2021. The reported cause of death was Acute heart failure. An autopsy was not performed. For mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular), the reporter considered CARDIAC FAILURE ACUTE (Acute heart failure) to be unlikely related. Treatment information was not provided. This is a case of death in a 74-year-old female subject with a medical history of dementia, arterial hypertension, metastatic breast cancer and glaucoma, who died 2 days after receiving a dose of vaccine. Based on the reporters comment and the information received, the cardiac failure is assessed as unlikely related to mRNA-1273. Reporter did not allow further contact; Sender''s Comments: This is a case of death in a 74-year-old female subject with a medical history of dementia, arterial hypertension, metastatic breast cancer and glaucoma, who died 2 days after receiving a dose of vaccine. Based on the reporters comment and the information received, the cardiac failure is assessed as unlikely related to mRNA-1273.; Reported Cause(s) of Death: Acute heart failure


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