In the past decade, enthusiasm for risk-based guidelines for the treatment of hypertensive patients, in which absolute risk profiles and individualized treatment strategies are employed, has steadily increased. This stems from the recognition that hypertension is only one of the risk factors for cardiovascular disease, and that the risk of morbidity or mortality in patients with mild hypertension depends more on their constellation of risk factors than on their actual blood pressure reading. While risk-based guidelines do offer some advantages over traditional guidelines, they also have important shortcomings that should be acknowledged. In particular, the use of risk-based guidelines does not obviate the need to set treatment thresholds. This is the key issue in any guideline because the treatment threshold determines the proportion of the population who will require treatment, the total cost of treatment, the number needed to treat to prevent one adverse event and the cost effectiveness of medical care. The advantages and shortcomings of risk-based guidelines are discussed and a method is proposed whereby the preferences of patients, practicing physicians, and the general public can be determined and incorporated into future hypertension guidelines.