The ZWOlle Transmural Integrated Care for CArdiovaScular Risk Management Study

Inclusion criteria for patients with CVD: * Patients with a history of atherosclerotic CVD defined as documented angina pectoris, myocardial infarction, chronic ischemic heart disease, coronary sclerosis, transient ischaemic attack (TIA), cerebral infarction, intermittent claudication or aneurysm of the abdominal aorta * The CV risk of the patient is managed in primary care, not in the hospital or outpatient clinic by a medical specialist * Age between 40 and 80 years Inclusion criteria for high risk patients: * Use of blood pressure lowering or lipid lowering drugs * A 10 -years CV risk \> 10%, based on the Dutch guideline for CVRM and i) either 1 strongly cardiovascular risk enhancing factor or 2 mildly cardiovascular risk enhancing factors (see table 6) or ii) \> 1 CV risk factor (current smoking, SBP\>140 mmHg, LDL\>2.5 mmol/L, TC/HDL-ratio \> 8, chronic renal impairment (age \< 65 years: eGFR \< 60 ml/min/1,73 m2; age ≥ 65 years: eGFR \< 45 ml/min/1,73 m2, and/or (micro)albuminuria). * A 10-year CV risk of \>20% and \> 1 CV risk factor (current smoking, SBP\>140 mmHg, LDL\>2.5 mmol/L, TC/HDL-ratio \> 8, chronic renal impairment (age \< 65 years: eGFR \< 60 ml/min/1,73 m2; age ≥ 65 years: eGFR \< 45 ml/min/1,73 m2, and/or (micro)albuminuria). * The CV risk of the patient is managed in primary care, not in the hospital or outpatient clinic by a medical specialist * Age between 40 and 80 years Exclusion criteria for all patients: * Diabetes mellitus, as these patients …