Inclusion Criteria- Men and women over 40 years of age, who meet at least one of the following criteria:
1. have established cardiovascular disease: Coronary Artery Disease, Cerebrovascular disease (documented stroke and/or TIA), and Peripheral Vascular Disease;
2. have Diabetes Mellitus;
3. have Chronic Kidney Disease ;
4. are at high risk for CVD based on a presence of at least three of the following established cardiovascular risk factors: age (males ≥ 45, females ≥ 55), smoker status, hypertension, and dyslipidemia.
- No restrictions will be imposed on the recruitment process; all practices in the region will be eligible to participate.