The Perceived Stress Scale-10 as a screening tool for impaired atrial fibrillation-specific quality of life: Identification of an optimal cut-off value and incremental screening value

Abstract Background To determine the optimal cutoff of the 10-item Perceived Stress Scale (PSS-10) for screening impaired atrial fibrillation (AF)-specific quality of life (QoL), and evaluate its incremental value beyond routine clinical variables. Methods We performed a secondary analysis of a publicly available cross-sectional dataset of 196 community-dwelling adults with AF (Rush et al., PLoS One 2023). Impaired QoL was defined as an AFQoL-16 score at or below the 25th percentile (57.41 points). Associations were assessed by Spearman’s correlation and multivariate logistic regression. ROC analysis identified the optimal cutoff. Incremental value over a base model (age, sex, time since last AF episode, self-rated overall health) was evaluated by DeLong test, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA). Results Forty-nine patients (25.0%) had impaired QoL. PSS-10 was inversely correlated with AFQoL score (rs=-0.385, P < 0.001), with each 1-point increase conferring 11.3% higher odds of impaired QoL. The AUC was 0.701 (95%CI 0.617–0.784); the optimal cutoff was ≥ 16 points (sensitivity 57.1%, specificity 78.2%). Adding PSS-10 to the base model increased AUC from 0.769 to 0.827 (NRI 0.490, P = 0.005; IDI 0.062, P = 0.006), with DCA confirming greater net benefit across clinically relevant thresholds. Conclusions PSS-10 is independently associated with AF-specific QoL impairment. A cutoff of 16 points offers acceptable screening performance and significant incremental value beyond routine variables, supporting its use as a simple first-line screening tool, though external validation in independent cohorts is needed.