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From the 8/20/2021 release of VAERS data (an older release, current is 1/7/2022):

This is VAERS ID 1022552

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Case Details

VAERS ID: 1022552 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-14
Onset:2021-01-21
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L204 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death
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: 2021-01-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: amiodarone (PACERONE) 200 mg tablet aspirin 81 mg chewable tablet(Expired) atorvastatin (Lipitor) 40 mg tablet cholecalciferol, vitamin D3, (VITAMIN D3) 1,000 unit capsule furosemide (LASIX) 40 mg tablet LORazepam (Ativan) 0.5 mg tablet met
Current Illness: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia Other ICD (implantable cardioverter-defibrillator) in place Increased BMI
Preexisting Conditions: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia Other ICD (implantable cardioverter-defibrillator) in place Increased BMI
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died of cardiac arrest on 01/21/2021


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