Age: 83.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Lipids, Metabolic function test, Myocardial infarction, Thyroid function test, Ultrasound Doppler
Clinical narrative: Inferior MI (Myocardial infarction); Loss of balance; This is a spontaneous report received from contactable reporter(s) (Physician and Nurse).  An 83-year-old male patient received BNT162b2 (BNT162B2), on 17Feb2021 as dose 2, single (Lot number: EM9809) at the age of 83 years intramuscular for covid-19 immunisation. The patient's relevant medical history included: "SVT", start date: 2014 (ongoing), notes: SVT, Stable/managed by cardiology; "HTN", start date: 2014 (ongoing), notes: HTN, Stable/managed by cardiology; "BPH" (ongoing), notes: BPH; "Anxiety" (ongoing); "Insomnia" (ongoing); "Hyperlipidemia" (ongoing); "Pancytopenia", start date: 2016 (ongoing), notes: Managed by hematology recently worsened Sep2022.; "Thrombocytopenia", start date: 2016 (ongoing), notes: Managed by hematology recently worsened Sep2022.; "Leukopenia (mild)", start date: 2016 (ongoing), notes: Managed by hematology recently worsened Sep2022.; "Splenomegaly", start date: 2016 (ongoing), notes: Managed by hematology. Concomitant medication(s) included: METOPROLOL SUCCINATE oral taken for supraventricular tachycardia (ongoing); LOSARTAN POTASSIUM oral taken for hypertension (ongoing); TAMSULOSIN oral taken for benign prostatic hyperplasia (ongoing); CLONAZEPAM oral taken for anxiety, insomnia (ongoing); ATORVASTATIN oral taken for hyperlipidaemia (ongoing); OMEPRAZOLE oral (ongoing); ASPIRIN [ACETYLSALICYLIC ACID] oral (ongoing); VITAMIN D [COLECALCIFEROL] oral (ongoing). Vaccination history included: BNT162b2 (Dose: 01, Route of administration: Intramuscular, Batch/Lot number: EL9261), administration date: 25Jan2021, when the patient was 83-year-old, for COVID-19 immunization. The following information was reported: MYOCARDIAL INFARCTION (medically significant) with onset Apr2021, outcome "unknown", described as "Inferior MI (Myocardial infarction)"; BALANCE DISORDER (non-serious) with onset 2021, outcome "recovered" (2021), described as "Loss of balance". The patient underwent the following laboratory tests and procedures: Catheterisation cardiac: (07Apr2021) Right coronary artery occlusion, notes: RCA occlusion, Mild L CAD, moderate left ventricular dysfunction; Echocardiogram: (08Apr2021) Mild left ventricular hypertrophy; Ejection fraction: (08Apr2021) 55 %; Full blood count: (unspecified date) unknown resuls, notes: monitored routinely; Lipids: (unspecified date) unknown resuls; Metabolic function test: (unspecified date) unknown resuls; Thyroid function test: (unspecified date) unknown resuls; Ultrasound Doppler: (14May2021) Negative. Therapeutic measures were taken as a result of myocardial infarction. Additional information: Patient received first COVID vaccine on 25Jan2021 no reported reaction. He received second vaccine on 17Feb2021 and reported loss of balance for approximately 8 hours. The patient did not provide information to the reporter regarding the reported adverse event(s) with the use of the product. The reporter considered the Pfizer product had a causal effect to the adverse events. Patient had revascularization of RCA-0 Stents placed during cardiac catheterization (04Aug2021).; Sender's Comments: Based on the available information, there is reasonable possibility of causal association between the events  balance disorder, myocardial infaction  and the suspect drug  BNT162b2 .