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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1333066

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Case Details

VAERS ID: 1333066 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-03-01
Onset:2021-04-03
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain lower, Cardiac death, Chills, Fatigue, 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), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: BISOPROLOL; XARELTO; PERINDOPRIL; ATORVASTAX; XENALON
Current Illness: Atrial fibrillation; Drug allergy (Allergy to Acemetacin); Heart failure; Hypercholesterolemia; Hypertension
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: CHMODERNATX, INC.MOD20211

Write-up: found unconscious; cardiac death; considerable exhaustion; severe pain in the lower abdomen; chills; This regulatory authority case was reported by a physician (subsequently medically confirmed) and describes the occurrence of CARDIAC DEATH (cardiac death) and LOSS OF CONSCIOUSNESS (found unconscious) in a 79-year-old male patient who received mRNA-1273 (COVID-19 Vaccine Moderna) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Atrial fibrillation, Hypertension, Hypercholesterolemia, Heart failure and Drug allergy (Allergy to Acemetacin). Concomitant products included BISOPROLOL from 29-Sep-2020 to an unknown date, RIVAROXABAN (XARELTO) from 26-Mar-2015 to an unknown date, PERINDOPRIL from 26-Mar-2014 to an unknown date, ATORVASTATIN CALCIUM (ATORVASTAX) from 29-Apr-2014 to an unknown date and SPIRONOLACTONE (XENALON) from 25-Jan-2019 to an unknown date for an unknown indication. In March 2021, the patient received first dose of mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 02-Apr-2021, received second dose of mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. On 03-Apr-2021, the patient experienced CHILLS (chills). On 04-Apr-2021, the patient experienced ABDOMINAL PAIN LOWER (severe pain in the lower abdomen). On 05-Apr-2021, the patient experienced CARDIAC DEATH (cardiac death) (seriousness criterion death) and FATIGUE (considerable exhaustion). On an unknown date, the patient experienced LOSS OF CONSCIOUSNESS (found unconscious) (seriousness criterion medically significant). On 05-Apr-2021, LOSS OF CONSCIOUSNESS (found unconscious) outcome was unknown. The patient died on 05-Apr-2021. The reported cause of death was suspected sudden cardiac death. It is unknown if an autopsy was performed. At the time of death, ABDOMINAL PAIN LOWER (severe pain in the lower abdomen), CHILLS (chills) and FATIGUE (considerable exhaustion) outcome was unknown. For mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular), the reporter considered CARDIAC DEATH (cardiac death) to be unlikely related. No further causality assessments were provided for LOSS OF CONSCIOUSNESS (found unconscious), ABDOMINAL PAIN LOWER (severe pain in the lower abdomen), CHILLS (chills) and FATIGUE (considerable exhaustion). Follow-up received on 13-May-2021 was significant and included the appended translation document and additional information based on the narrative was updated. On an unspecified date, it was reported that the patient developed severe pain in the lower abdomen two days after the second dose of covid-19 vaccine and made an emergency medical visit. No treatment information was provided, but it was reported that "nothing in particular" was found. It was reported that the pain improved, but the patient experienced considerable exhaustion. On an unspecified date, three days after the vaccination, it was reported that the patient was found unconscious and resuscitation was unsuccessful. Based on the current available information and temporal association between the use of the product and the death, a causal relationship cannot be excluded, although the patient''s concurrent conditions were likely related to their death. Awaiting translation for additional information. Sender''s Comment: Sudden cardiac death in a 79-year-old patient known to have heart disease 3 days after the second injection of the Moderna covid-19 vaccine. The countries monograph for the Moderna covid-19 vaccine does not list cases of death under the side effects (1). The database, in the Moderna covid-19 vaccine monograph (2), out of 49,811 reports, lists 1441 cases of death. In light of the literature data and information available to us, considering the cardiological comorbidities of the patient, despite the close temporal link, we consider a link between the sudden cardiac death and the Moderna covid-19 vaccine as unlikely. This view on causality cannot, however, entirely rule out the role/contribution of the vaccine. Company Comment: Limited information regarding the events has been provided at this time and a causal relationship cannot be excluded. Cause of death not provided, although the patient''s concurrent conditions were possibly related to their death. Most recent FOLLOW-UP information incorporated above includes: On 06-May-2021: Translated document received on 13 MAY 2021 with no new information; Sender''s Comments: Limited information regarding the events has been provided at this time and a causal relationship cannot be excluded. Cause of death not provided, although the patient''s concurrent conditions were possibly related to their death. .; Reported Cause(s) of Death: Suspected sudden cardiac death


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