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

This is VAERS ID 1419198

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Case Details

VAERS ID: 1419198 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-05-06
Onset:2021-05-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Death, Hypertensive heart disease, Respiratory arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypertension (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-08
   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: DEPON; DIAMICRON; LOBIVON; ORIZAL
Current Illness: Type 2 diabetes mellitus
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: GRMODERNATX, INC.MOD20212

Write-up: Death; Arrest respiratory; Hypertensive heart disease; Arrest cardiac; This regulatory authority case was reported by a consumer and describes the occurrence of DEATH (Death), RESPIRATORY ARREST (Arrest respiratory), HYPERTENSIVE HEART DISEASE (Hypertensive heart disease) and CARDIAC ARREST (Arrest cardiac) in an 80-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) for COVID-19 vaccination. Concurrent medical conditions included Type 2 diabetes mellitus. Concomitant products included PARACETAMOL (DEPON), GLICLAZIDE (DIAMICRON), NEBIVOLOL HYDROCHLORIDE (LOBIVON) and AMLODIPINE BESILATE, OLMESARTAN MEDOXOMIL (ORIZAL) for an unknown indication. On 06-May-2021, the patient received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. On an unknown date, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (unknown route) 1 dosage form. On 08-May-2021, the patient experienced DEATH (Death) (seriousness criteria death and medically significant), RESPIRATORY ARREST (Arrest respiratory) (seriousness criteria death and medically significant), HYPERTENSIVE HEART DISEASE (Hypertensive heart disease) (seriousness criteria death and medically significant) and CARDIAC ARREST (Arrest cardiac) (seriousness criteria death and medically significant). The patient died on 08-May-2021. The reported cause of death was Arrest cardiac, Arrest respiratory and Hypertensive heart disease. An autopsy was not performed. No treatment information was provided. Action taken with Moderna Covid vaccine was not applicable. Very limited information regarding this events has been provided at this time. Further information is not expected. Most recent FOLLOW-UP information incorporated above includes: On 10-Jun-2021: Concomitant medication has been added; Sender''s Comments: Very limited information regarding this events has been provided at this time. Further information is not expected; Reported Cause(s) of Death: Arrest cardiac; Arrest respiratory; Hypertensive heart disease


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