Income Insufficiency, Type 2 Diabetes, and Perceived Stress in Cardiac Arrhythmia Outpatients: A Cross-Sectional...

Background and Objectives: Atrial fibrillation (AF) and related arrhythmias carry a substantial psychosocial burden that current cardiology guidelines do not systematically address. Whether economic strain and type 2 diabetes mellitus (T2DM) cluster with high perceived stress in arrhythmia outpatients remains untested in Arab populations. The objective of this study was to estimate the prevalence of high perceived stress and to identify its independent sociodemographic and clinical correlates in Saudi outpatients with cardiac arrhythmia, with an a priori focus on income insufficiency and type 2 diabetes mellitus. Materials and Methods: Between December 2025 and January 2026, 282 adults with clinician-documented arrhythmia attending a tertiary cardiology clinic in Saudi Arabia completed a structured questionnaire including an Arabic 10-item Perceived Stress Scale (PSS-10) previously validated in Arabic-speaking populations. High perceived stress was defined as a PSS-10 score of 20 or higher. A theoretically specified multivariable logistic regression with Firth penalisation identified independent correlates. Three sensitivity analyses were prespecified, and the latent structure of the Arabic PSS-10 was examined by split-sample exploratory and confirmatory factor analysis. Reporting follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Results: Sixty-nine participants (24.5%; 95% confidence interval [CI], 19.7-29.9) met the high-stress threshold (mean PSS-10 15.5; standard deviation [SD] 9.1). Income insufficiency (adjusted odds ratio [aOR] 2.09; 95% CI, 1.16-3.78; p = 0.014) and T2DM (aOR 2.51; 95% CI, 1.39-4.55; p = 0.002) were independently associated with high perceived stress; age and sex were not. The Arabic PSS-10 showed a two-factor structure (62.8% common variance) with acceptable confirmatory fit (root mean square error of approximation [RMSEA] = 0.078; 90% CI, 0.058-0.098; comparative fit index [CFI] = 0.945; Tucker-Lewis index [TLI] = 0.927; standardised root mean square residual [SRMR] = 0.052) and excellent reliability (Cronbach's α = 0.92). Conclusions: Roughly one in four Saudi outpatients with cardiac arrhythmia reports high perceived stress. The burden concentrates among those with income insufficiency or T2DM. Brief PSS-10 screening paired with onward referral to financial-navigation and diabetes-distress support warrants prospective evaluation as a low-cost, scalable component of routine arrhythmia care, with longitudinal designs needed to establish temporal sequence and intervention efficacy.