Pakistan looked to be heading for victory having posted a modest 229 for six wickets in their 50 overs, but the final West Indian pair of Holder and Kemar Roach struck 24 off 13 balls to leave the five-match series tied at 1-1.
Pakistan captain Misbah-ul-Haq opted to give seamer Wahab Riaz (1-63) the final over of the innings despite a poor showing in the match up to that point as he missed his lengths all too often.
Holder bludgeoned a six and a four to give his side hope. Needing three to win off the final ball, he flashed a thick edge to third man where Junaid Khan collected.
Khan's throw over the stumps looked certain to run out Holder and hand the victory to Pakistan but Akmal somehow failed to collect and the tailender was able to scramble home having scored an invaluable 19 off nine deliveries.
Lendl Simmonds had earlier struck a fluent 75 from 86 balls and put on 91 for the fourth wicket with Marlon Samuels (46) to put West Indies into a position to win the game.
However, excellent bowling from seamer Junaid (3-54) and off-spinner Saeed Ajmal (3-36) appeared to have taken the game away from them before Holder's heroics.
"I'm disappointed, this was a game we were supposed to win," West Indies captain Dwayne Bravo said in a television interview.
"It should never have reached that situation, leaving it to the lower order, given the number of batsmen we have. At this level, the number of dot balls in our innings was unacceptable. We need to come up with a plan to cut down on that, back to the drawing board."
Pakistan's innings was propped up by a fighting 75 from Misbah, with Akmal (40 not out) providing the only other score of real significance.
"The way Holder played he took the game away," Misbah said. "In the last over we bowled too many full deliveries. I thought 229 was a fighting total but in the end we missed a couple of tricks."
The fourth one-day international will be played at the same venue on Sunday.
(Reporting By Nick Said in Cape Town; Editing by Clare Fallon)
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