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

This is VAERS ID 1222742



Case Details

VAERS ID: 1222742 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Connecticut  
Vaccinated:2021-04-14
Onset:2021-04-16
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute coronary syndrome, Cardiogenic shock, Death
SMQs:, Cardiac failure (narrow), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol 500 mg PRN Aspirin 81 mg daily
Current Illness: Neutropenia Anemia Pericardial and right pleural effusions
Preexisting Conditions: None
Allergies: No known allergies to medications, food, or other products
Diagnostic Lab Data:
CDC Split Type:

Write-up: This patient was admitted to Hospital, and subsequently transferred with acute coronary syndrome and cardiogenic shock two days after receiving a COVID-19 vaccination. He died of complications of acute coronary syndrome on April 17, 2021.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1222742

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