Among developed and developing countries, Japan is facing the most rapid increase of aging population, where the proportion of citizens aged 75 or over will exceed 20% of the total population in 2040, and 25% in 2065. In the situation of an expanding healthcare cost because of an increase in elderly patients with multiple chronic comorbidities and newly-developed expensive drugs and medical devices, there is a multitude of issues such as uneven physician distribution by regions and specialties, lack of coordination between medical and nursing care, insufficient preparation for end-of-life or palliative care, and unestablished primary and secondary prevention systems. Under these circumstances, cardiovascular disease (including stroke) is the number one cause of death, bedridden, and use of national healthcare cost, surpassing cancer. In consideration of these aspects, we will discuss the appropriate cardiovascular care system and healthcare policy in Japan in the era of super-aging and healthcare cost expansion, to establish a more sustainable, efficient and equal healthcare system.