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From the 1/7/2022 release of VAERS data:

This is VAERS ID 1329787

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Case Details

VAERS ID: 1329787 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-05-03
Onset:2021-05-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EY3014 / 1 - / OT

Administered by: Other       Purchased by: ?
Symptoms: Death, Echocardiogram, Ejection fraction, Electrocardiogram ambulatory, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-05-03
   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: ANOPYRIN; SPIOLTO RESPIMAT; FORMOVENT; VASOCARDIN; ATORVASTATIN; VEROSPIRON; AMLORATIO; SEDACORON; BERODUAL; EUPHYLLIN [THEOPHYLLINE]; FOSINOPRIL SODIUM; FURON [FUROSEMIDE]; NOLPAZA
Current Illness: Arterial hypertension; Chronic venous insufficiency; COPD; Double vessel disease; Ex-smoker (Stopped smoking 2 years ago); Insufficiency cardiac (NYHA (New York Heart Association) scale: 3); Ischemic heart disease; Malleolus edema; Obesity (Grade: 3); Oxygen therapy (Long-term oxygentherapy at home); Paroxysmal atrial flutter; Peripheral arterial disease; Polyposis intestinal; Renal insufficiency; Sleep apnea syndrome
Preexisting Conditions: Medical History/Concurrent Conditions: Aortic bi-femoral bypass; Aortocoronary bypass; Coronary revascularization (coronarography - Severe damage of the coronary arteries); DVT of calf (Right lower limb); Dyspnea; Inferior myocardial infarction (Inapparent); Septic shock (Caused by intestine perforation); Thrombectomy (Of the aorto-bifemoral bypass)
Allergies:
Diagnostic Lab Data: Test Date: 20210503; Test Name: Echocardiography; Result Unstructured Data: Test Result:dysfunction, aneurysm, dilatation; Comments: Mild systolic dysfunction of the left ventricule, aneurysm of the inferior wall, mild dilatation of the left atrium; Test Date: 20210503; Test Name: Ejection fraction; Test Result: 45 %; Test Date: 20210503; Test Name: Holter monitoring; Result Unstructured Data: Test Result:Sinus rhythm; Comments: Sinus rhythm, infrequent isolated ventricule extrasystoles; Test Date: 20210503; Test Name: Holter monitoring; Result Unstructured Data: Test Result:severe bradycardia with frequency of 15 beats per; Comments: severe bradycardia with frequency of 15 beats per minute was seen at first, then it passed into ventricular fibrillation, then after defibrillation it passed into an isoelectric line
CDC Split Type: CZPFIZER INC2021544637

Write-up: death; Loss of consciousness; This is a spontaneous report from a contactable physician downloaded from the Regulatory Authority-WEB [CZ-CZSUKL-21005177]. A 70-year-old male patient received first dose of bnt162b2 (COMIRNATY, Batch/lot number EY3014), via intramuscular on 03May2021 at single dose for covid-19 immunization. Medical history included ongoing ischemic heart disease, ongoing chronic cardial insufficiency NYHA III, in Feb2014 coronary revascularization, coronarography - severe damage of the coronary arteries, in 2012 aortocoronary bypass, in 2012 inapparent myocardial infarction of the inferior wall, ongoing double vessel disease, ongoing chronic obstructive pulmonary disease, long-term oxygen therapy at home since Oct2019 and ongoing, ongoing sleep apnea syndrome, ongoing paroxysmal atrial flutter, ongoing arterial hypertension, ongoing renal insufficiency, ongoing peripheral arterial disease, in 2004 aorto-bifemoral bypass, in 2004 septic shock caused by intestine perforation, in Jan2019 bypass thrombectomy (Of the aorto-bifemoral bypass), ongoing chronic venous insufficiency, ongoing chronic perimalleolar oedemas, in Jun2018 deep venous thrombosis of the right calf (Right lower limb), ongoing large intestine polyposis, grade III obesity, ongoing ex-smoker for 2 years, and long lasting mild dyspnea. Concomitant medications included acetylsalicylic acid (ANOPYRIN); olodaterol hydrochloride, tiotropium bromide monohydrate (SPIOLTO RESPIMAT); formoterol fumarate (FORMOVENT); metoprolol tartrate (VASOCARDIN); atorvastatin; spironolactone (VEROSPIRON); amlodipine besilate (AMLORATIO); amiodarone hydrochloride (SEDACORON); fenoterol hydrobromide, ipratropium bromide (BERODUAL); theophylline (EUPHYLLIN); fosinopril sodium; furosemide (FURON); pantoprazole sodium sesquihydrate (NOLPAZA). The patient lost consciousness 2 minutes after being vaccinated (life-threatening). Cardiopulmonary resuscitation was started, including intubation and artifical ventilation. On electrocardiogram severe bradycardia with frequency of 15 beats per minute was seen at first, then it passed into ventricular fibrillation, then after defibrillation it passed into an isoelectric line. During resuscitation the patient was administered 2 mg of Atropin, 3 mg of Adrenalin, two electrical discharges and 75 mg of Amiodaron. Cardiopulmonal resuscitation was started at 13:02, at 13:50 it was stopped and the patient was proclaimed dead. Cause of death was unknown. Outcome of event loss of consciousness was not recovered. Autopsy was performed and no result available. The patient underwent lab tests and procedures on 03May2021 which included echocardiography: Mild systolic dysfunction of the left ventricule, aneurysm of the inferior wall, mild dilatation of the left atrium, ejection fraction: 45 %, holter monitoring: Sinus rhythm, infrequent isolated ventricule extrasystoles. No follow-up attempts possible. No further information expected.; Reported Cause(s) of Death: death


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