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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1304905

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Case Details

VAERS ID: 1304905 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Foreign  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-05-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   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:
Current Illness: Atrial fibrillation; Circulatory failure; Dementia (Dementia syndrome); Depressive disorder; Hypertension (hypertensive disease with heart involvement); Ischemic heart disease; Mitral valve insufficiency (Second / third mitral valve insufficience); Tricuspid regurgitation
Preexisting Conditions:
Diagnostic Lab Data:
CDC Split Type: PLPFIZER INC2021491352

Write-up: Cardiac arrest; This is a spontaneous report from a contactable physician. This is a report received from the Regulatory Authority, Regulatory authority report number PL-URPL-3-594-2021. The reporter is contactable to Health Authority only. An 86-year-old female patient received bnt162b2 (COMIRNATY, Batch/Lot Number: EW2243; Expiration Date: 31Jul2021), intramuscular, administered in Arm Left on 14Apr2021 16:17 (at the age of 86years) as 2ND DOSE, SINGLE for Covid-19 immunization. Medical history included treated chronically for hypertensive disease with heart involvement, permanent atrial fibrillation, chronic circulatory failure, ischemic heart disease, mitral valve insufficiency II degree/III degree and tricuspid valve regurgitation, depressive disorder with dementia syndrome; all ongoing. The patient''s concomitant medications were not reported. It was reported that on April 15, 2021 at 15:35, the patient died of cardiac arrest after the resuscitation action of the Emergency Medical Service. The patient died on 15Apr2021. It was unknown if an autopsy was performed. Causality assessment between the (Product Name) COMIRNATY and Reaction/Event: Cardiac arrest was Unlikely. (Source of assessment Regulatory Authority; Method of assessment WHO-UMC; Result of Assessment Unlikely) Sender''s comment: Cardiac arrest is unexpected symptom after vaccination with Comirnaty. Until April 22, 2021, 119 cases of cardiac arrest were reported in the pharmacovigilance database. There is a time relationship between the administration of the vaccine and the occurrence of the side effect. However, taking into account the patient''s medical history (e.g. ischemic heart disease, circulatory failure, hypertension), the Regulatory Authority believes that the cardiac arrest occurred in a temporary coincidence and that the vaccine administration was unlikely. The person reporting post vaccination adverse reaction qualified it as serious. Due to the health result: death, the Regulatory Authority assessed the post vaccination adverse reaction as serious. No follow-up attempts are possible. No further information is expected. Information on lot number already obtained.; Reported Cause(s) of Death: cardiac arrest

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