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

This is VAERS ID 1579233

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Case Details

VAERS ID: 1579233 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-07-14
Onset:2021-07-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-08-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3003187 / 1 - / OT

Administered by: Unknown       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: 2021-07-14
   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: COVERSYL [PERINDOPRIL ARGININE]; KARDEGIC; CARDENSIEL; LASILIX [FUROSEMIDE]; PROCORALAN
Current Illness: Hypertension arterial
Preexisting Conditions: Medical History/Concurrent Conditions: Chronic respiratory failure; Death of brother cardiac arrest; Left ventricular ejection fraction (40%); Overweight; smoking
Allergies:
Diagnostic Lab Data:
CDC Split Type: FRMODERNATX, INC.MOD20212

Write-up: This case was received via Regulatory Authority (Reference number: AM20212231) on 09-Aug-2021 and was forwarded to Moderna on 09-Aug-2021. This regulatory authority case was reported by a pharmacist and describes the occurrence of CARDIAC ARREST in a 52-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3003187) for COVID-19 vaccination. The patient''s past medical history included Smoking, Overweight, Left ventricular ejection fraction (40%) and Chronic respiratory failure. Family history included Death of brother; cardiac arrest. Concurrent medical conditions included Hypertension arterial. Concomitant products included PERINDOPRIL ARGININE (COVERSYL [PERINDOPRIL ARGININE]), ACETYLSALICYLATE LYSINE (KARDEGIC), BISOPROLOL FUMARATE (CARDENSIEL), FUROSEMIDE (LASILIX [FUROSEMIDE]) and IVABRADINE HYDROCHLORIDE (PROCORALAN) for an unknown indication. On 14-Jul-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 14-Jul-2021, after starting mRNA-1273 (COVID 19 Vaccine Moderna), the patient experienced CARDIAC ARREST (seriousness criteria death and medically significant). The patient died on 14-Jul-2021. The reported cause of death was cardiac arrest. 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 to the event was not reported. Based on the current available information and temporal association between the use of the product and the event, a causal relationship cannot be excluded. Event term, onset date and outcome captured per Authority reporting. Event seriousness per assessment by Authority and per list.; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the event, a causal relationship cannot be excluded. Event term, onset date and outcome captured per Authority reporting. Event seriousness per assessment by Authority and per list; Reported Cause(s) of Death: cardiac arrest.


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